Citation Nr: 18157559 Decision Date: 12/12/18 Archive Date: 12/12/18 DOCKET NO. 08-31 838 DATE: December 12, 2018 ORDER Service connection for hypertension is denied. REMANDED Entitlement to service connection for a left hip disorder, to include as secondary to service-connected bilateral knee disabilities, is remanded. Entitlement to service for a right hip disorder, to include as secondary to service-connected bilateral knee disabilities, is remanded. Entitlement to service connection for a back disorder, to include as secondary to service-connected bilateral knee disabilities, is remanded. Entitlement to service connection for bilateral lower extremity sciatica, to include as secondary to a back disorder, is remanded. FINDING OF FACT Hypertension is not shown to be caused or aggravated by the Veteran’s service-connected bilateral knee disabilities. CONCLUSION OF LAW The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from December 1959 to July 1965. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a rating decision issued in November 2009 by a Department of Veterans Affairs (VA) Regional Office. While the Veteran previously requested a Board hearing in connection with the issues on appeal, he later withdrew his request in July 2010 and April 2015. Consequently, there are no hearing requests pending. In April 2012, the Board remanded the case for additional development. Thereafter, the Board denied the claims on appeal in a June 2016 decision. Subsequently, the Veteran appealed such decision to the United States Court of Appeals for Veterans Claims (Court). In February 2017, the Court granted the Veteran’s and the Secretary of VA’s (the parties) Joint Motion for Partial Remand (JMPR), which vacated and remanded the Board’s June 2016 decision as to such issues for action consistent with the JMPR. In this regard, the Court did not address, or find fault with, the Board’s denial of service connection of such claims on a direct basis. Accordingly, the Board’s June 2016 decision on such theories of entitlement is final. Thereafter, in July 2017, the Board remanded the claims on appeal for additional development and they now return for further appellate review. 1. Entitlement to service connection for hypertension, to include as secondary to service-connected bilateral knee disabilities. 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). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). 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) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Further, service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310 (b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran is seeking service connection for hypertension. Specifically, he contends that such disorder is caused or aggravated by his service-connected bilateral knee disabilities. In this regard, the Veteran was afforded a VA examination in September 2009 to determine the nature and etiology of his hypertension. At such time, the examiner opined that it was less likely as not that the Veteran’s hypertension was the result of his right and left knee replacements because the Veteran claimed that he had no pain in both knees and that both knee surgeries were a success. The examiner also opined that it was less likely as not that the Veteran’s hypertension was the result of his original knee pain prior to surgery because, per the Veteran, his knee condition started in 1965 and the hypertension started in 1983. However, the Board found that such examiner did not provide a clear rationale as to why the Veteran’s hypertension was not caused by or aggravated by his service-connected bilateral knee disabilities. Accordingly, the Veteran was afforded another VA examination in August 2013. At such time, the examiner opined that his hypertension was less likely than not caused by or aggravated by his service-connected bilateral knee disabilities. In support thereof, the examiner explained that, while documenting knee complaints, the Veteran’s service treatment records were silent for evidence of hypertension. Further, the record was significant for documentation of hypertension beginning in 1994, and a review of current medical literature revealed that the medically accepted risk factors for hypertension included age (the Veteran was age 50 at onset in 1993), being overweight (the Veteran’s body mass index was 29.6 at time of onset), and tobacco use (positive prior history). Thus, the examiner concluded that the most likely cause for the Veteran’s hypertension were his risk factors at the time of diagnosis. Consequently, in June 2016, the Board denied the Veteran’s claim for service connection for hypertension based on the August 2013 VA examination. However, in the JMPR, the parties determined that the August 2013 VA examiner’s opinion was inadequate as to the question of whether the Veteran’s hypertension was aggravated by his service-connected bilateral knee disabilities because the examiner’s rationale only focused on what caused the hypertension and did not address whether such disorder was aggravated by the Veteran’s service-connected bilateral knee disabilities. Thus, pursuant to the July 2017 remand, the Veteran underwent another VA examination in October 2017. At such time, the examiner opined that the Veteran’s hypertension was not at least as likely as not aggravated beyond its natural progression by his service-connected bilateral knee disabilities. In support thereof, she explained that the Veteran’s blood pressure readings were not currently under control because he did not take his medication. The examiner also noted that the Veteran’s right knee condition was diagnosed in service and his left knee condition was diagnosed decades later. She explained that neither knee condition aggravated the Veteran’s blood pressure, which was in good control until his self-management to not take his medications. The Board has carefully reconsidered the facts of this case, including the concerns raised in the JMPR. Ultimately, the appeal must again be denied because the preponderance of the evidence weighs against the Veteran’s claim. In this regard, the Board places great probative weight on the August 2013 and October 2017 VA opinions that the Veteran’s hypertension was not caused or aggravated by his service-connected bilateral knee disabilities. Specifically, such VA opinions focused on the complex medical questions in the case, including the concerns raised in the JMPR. Furthermore, such opinions considered all of the pertinent evidence of record, and provided a detailed rationale for the conclusions reached, relying on and citing to the records reviewed. Moreover, the examiners offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); 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”). There is no medical opinion to the contrary. The Board notes that the Veteran has contended on his own behalf that his current hypertension is caused or aggravated by his service-connected bilateral knee disabilities. The Veteran, as a layperson, is certainly competent to report matters within his personal knowledge, such as the occurrence of an injury or event, or his own symptoms. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). However, in the instant case, the Board finds that the question regarding the potential relationship between hypertension and his service-connected bilateral knee disabilities to be complex in nature. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although 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). In this regard, while the Veteran is competent to describe the current manifestations of his hypertension as well as his history of claimed symptoms and treatment for such disorder, the Board accords such statements regarding the etiology of such disorder little probative value as he is not competent to opine on such complex medical questions. Specifically, where the determinative issue is one of medical causation and/or aggravation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. Brown, 7 Vet. App. 134, 137 (1994). In this regard, the question of the etiology of hypertension, to include the relationship to the Veteran’s bilateral knee disability, involves an internal process that is beyond an immediately observable cause-and-effect relationship. There is no indication that the Veteran possesses the requisite medical knowledge regarding the causes of hypertension and the impact his bilateral knee disabilities may have on such a diagnosis. Moreover, he has offered only conclusory statements regarding the relationship between his service-connected bilateral knee disabilities and his current hypertension. See Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). Therefore, the Board affords the Veteran’s statements as to the etiology of his hypertension no probative weight. Therefore, based on the foregoing, the Board finds that the Veteran’s hypertension is not caused or aggravated by his service-connected bilateral knee disabilities. As such, service connection for such disorder is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim for service connection for hypertension, that doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. REASONS FOR REMAND 2. Entitlement to service connection for a left hip disorder, to include as secondary to service-connected bilateral knee disabilities. 3. Entitlement to service for a right hip disorder, to include as secondary to service-connected bilateral knee disabilities. 4. Entitlement to service connection for a back disorder, to include as secondary to service-connected bilateral knee disabilities. 5. Entitlement to service connection for bilateral lower extremity sciatica, to include as secondary to a back disorder. The Board finds that a remand is necessary to obtain an addendum opinion to determine whether the Veteran’s current bilateral hip disorder, back disorder, and bilateral lower extremity sciatica were aggravated by his service-connected bilateral knee disabilities. In this regard, pursuant to the July 2017 remand, the Veteran was afforded VA examinations in October 2017. However, the examiner did not provide an adequate opinion as to whether the Veteran’s service-connected bilateral knee disabilities aggravated his bilateral hip disorder and/or his back disorder, including his associated sciatica. Rather, with regard to the Veteran’s bilateral hip disorder, the examiner noted that the Veteran did not have physical complaints referable to the hip joints and that the X-rays showed mild, age-related, and expected degenerative joint disease (DJD) of the hips in 2009, when discussing the baseline level of severity. However, such still does not explain whether the Veteran’s bilateral knee disabilities aggravated his bilateral hip disorder. Additionally, with regard to the Veteran’s back disorder, the examiner noted that the Veteran’s back conditions were not due to his knees in that there was no temporal connection between knee complaints and back complaints, which started when he was hit in the back with a board, more than a decade after his military service. The examiner also noted that there was no documentation in the medical records that there was an association between the Veteran’s work and his motor vehicle accident-related back complaints, and his service-connected knee complaints. However, the examiner appears to have focused on what caused the Veteran’s back disorder instead of addressing rather his bilateral knee disabilities aggravated such disorder. Furthermore, upon examination, the examiner found that there was no objective evidence of paralysis of the sciatica nerve and that such had either resolved or was misdiagnosed during the August 2013 VA examination. However, the examiner is advised that the Veteran has a current diagnosis of bilateral lower extremity sciatica as the Veteran was diagnosed with such disorder during the pendency of the claim, even if it has resolved. See McClain v. Nicholson, 21 Vet. App. 319 (2007). Thus, the Board finds that a remand is necessary to obtain an addendum opinion that addresses such concerns. The matters are REMANDED for the following action: Return the record to the VA examiner who conducted the October 2017 examination of the Veteran’s back and bilateral hip disorders. The record and a copy of this Remand must be made available to the examiner. If the October 2017 VA examiner is not available, the record should be provided to an appropriate medical professional so as to render the requested opinion. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. (A) For the Veteran’s bilateral hip disorder, diagnosed as bilateral hip degenerative joint disease, the examiner should offer an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s service-connected bilateral knee disabilities aggravated such disorder? For any aggravation found, the examiner should state, to the best of their ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology by the aggravation. (B) For the Veteran’s back disorder, to include sciatica, diagnosed as lumbar spine degenerative disk disease/degenerative joint disease and bilateral lower extremity sciatica, the examiner should offer an opinion as to whether it is at least as likely as not that the Veteran’s service-connected bilateral knee disabilities aggravated such disorders? For any aggravation found, the examiner should state, to the best of their ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology by the aggravation. The examiner should note that aggravation in this context means “any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease.” 38 C.F.R. § 3.310(b) (emphasis added). A rationale for any opinion offered should be provided. A. JAEGER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. Clark, Associate Counsel