Citation Nr: 18160848 Decision Date: 12/28/18 Archive Date: 12/27/18 DOCKET NO. 17-07 014 DATE: December 28, 2018 ORDER Entitlement to a compensable disability rating for hypertension is denied. Entitlement to service connection for headaches is denied. Entitlement to service connection for back disorder is denied. Entitlement to service connection for right-foot disorder is denied. FINDINGS OF FACT 1. The objective medical evidence shows that during the appeal period hypertension has not been manifested by diastolic pressure of predominantly 100 or more or systolic blood pressure predominantly 160 or more and the medical evidence shows that it has otherwise been controlled with medication. 2. The objective medical evidence shows that continuing headaches are not caused by an event, injury or illness during active service, nor were they etiologically related to it. 3. The objective medical evidence shows that a continuing back disorder is not caused by an event, injury or illness during active service. 4. The objective medical evidence shows that a continuing right-foot disorder is not caused by an event, injury or illness during active service. CONCLUSIONS OF LAW 1. The criteria for an evaluation for a compensable rating for hypertension are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.31, 4.104, Diagnostic Code 7101 (2017). 2. The criteria for service connection for chronic headaches are not met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 3. The criteria for service connection for a chronic back disorder are not met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 4. The criteria for service connection for a chronic right-foot disorder are not met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Navy from June 2008 to June 2012. 1. Entitlement to a compensable disability rating for hypertension. Increased Schedular Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule), found in 38 C.F.R. Part 4. Disability ratings are intended to compensate impairment in earning capacity due to a service connected disorder. 38 U.S.C. § 1155. The evaluation of a service-connected disorder requires a review of a veteran’s entire medical history regarding that disorder. 38 U.S.C. § 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When a reasonable doubt arises regarding the degree of disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7. 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; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Additionally, it is possible for a veteran to be awarded separate percentage evaluations for separate periods (staged ratings), based on the facts. See Fenderson v. West, 12 Vet. App. 119, 126–27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where an increase in the disability rating is at issue, the present level of the veteran’s disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The record shows that the Veteran’s hypertension has been evaluated under Diagnostic Code 7101. Under its provisions, a rating of 10 percent requires diastolic blood pressure predominantly 100 or more, or systolic blood pressure predominantly 160 or more, or minimum evaluation for an individual with a history of diastolic blood pressure predominantly 100 or more who requires continuous medication for control. A rating of 20 percent requires diastolic blood pressure predominantly 110 or more, or systolic blood pressure predominantly 200 or more. A rating of 40 percent requires diastolic pressure predominantly 120 or more. A rating of 60 percent requires diastolic blood pressure predominantly 130 or more. 38 C.F.R. § 4.104, Diagnostic Code 7101. Hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. Id. Additionally, the above diagnostic code will be interpreted and implemented in conjunction with 38 C.F.R. §4.31, which states: In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. Accordingly, the June 2015 rating decision granted the Veteran’s claim for service connection for hypertension at a noncompensable rating, effective November 25, 2014. Evidence Looking to the record, in June 2014 the Veteran presented for a follow-up examination to her private treatment provider. She was taking hydrochlorothiazide, her blood pressure readings were 111 (systolic) over 67 (diastolic), indicating a lower than normal reading and her treatment provider noted that it was well controlled. In a September 2014 visit, blood pressure was 149/88. In December 2014, it was 127/74. In April 2015, the Veteran underwent a VA examination for hypertension, the results of which are the basis for the June 2015 grant of service connection at a noncompensable disability rating. The April 2015 restated the Veterans 2009 diagnosis of hypertension. Readings to establish that diagnosis was set forth as 130/90 in November 2009; 155/114 in August 2009; and 148/100 in July 2009, for an average of 146/97. Blood pressure readings for that day’s examination were 140/80, 138/78 and 136/82 for an average of 138/80. The April 2015 VA examiner noted that the Veteran’s in-service pregnancy had been complicated by hypertension requiring treatment with Labetalol. After the pregnancy, the Veteran was found to have ongoing elevated blood pressures and started treatment with hydrochlorothiazide. A June 2015 wellness visit to the Veteran’s private treatment provider shows that blood pressure was at 131/77. November 2015 visits for other complaints produced blood pressure readings of 115/80 and 132/87. In a January 2016 visit, blood pressure was 117/72. The Veteran’s VA visits to her primary care physician show February 2016 blood pressure at 118/78. In March 2016, it was 142/92. However, her primary care physician observed that the Veteran’s benign essential hypertension may in fact be “white-coat hypertension,” by which she exhibits a blood pressure level above the normal range in a medical clinical setting only, due to anxiety. Discussion As plainly indicated above, at no time between June 2014 and March 2016 does any diastolic reading reach 100 or more, nor do systolic readings ever reach 160 or more, as required for a minimal compensable rating of 10 percent under Diagnostic Code 7101. Only in readings recorded in the April 2015 VA examination from 2009, well before the effective date of the Veteran’s grant of service connection at a noncompensable rating, had a diastolic reading of 100 or more been twice reached. Moreover, the Board notes from the May 2015 treatment summary that from April 2010 to December 2010 the Veteran’s dosage of the hypertension medication of hydrochlorothiazide was 12.5 mg per day. From December 2010 to March of 2012, the dosage increased to 25 mg per day. By June 2014, the above follow-up visit to her private treatment provider shows the Veteran was now at 50 mg per day. This prescribed dosage was in place during the Veteran’s March 2016 VA primary care outpatient visit. The foregoing suggests that between April 2010 and March 2012 the amount of hydrochlorothiazide per day was calibrated to achieve the necessary control of the Veteran’s hypertension. It appears at some time before June 2014, the dose again had been increased and by June 2014 was described as “well controlled.” Significantly, nothing in the record following that date shows the need for a further increase in medication and by the March 2016 VA primary care outpatient follow-up visit, which appears to be the latest hypertension treatment note in the record, the Veteran was still taking hydrochlorothiazide at 50 mg per day. Moreover, elevated ratings such as to warrant a compensable rating were not shown with the increase in medication. This is to say, that no further adjustment was deemed necessary by a private or VA treatment providers and the sparse treatment record itself further suggests that the Veteran was not impelled by symptoms to seek an increase in medication or any treatment beyond monitoring. From this, the Board reasonably concludes, based on the medical evidence provided to it, that the Veteran’s hypertension disability has not worsened, as there is no medical evidence to support such a finding. Moreover, the Board notes that even the above March 2016 VA treatment provider had expressed some doubt as to the Veteran’s higher or variable blood pressure readings, based on what he perceived to be the Veteran’s anxiety during examinations. For these reasons and based on the objective medical evidence, the Board finds that during the appeal period hypertension has not been manifested by diastolic pressure of predominantly 100 or more or systolic blood pressure predominantly 160 or more and the medical evidence shows that it has otherwise been controlled with medication. Consequently, a compensable disability rating for hypertension is not warranted. Service Connection Generally, service connection may be granted for disability arising from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for a disability requires evidence of: (1) The existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). See also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff’d, 78 F.3d 604 (Fed. Cir. 1996). 2. Entitlement to service connection for headaches. Evidence The Veteran’s September 2007 medical pre-screen interview and October 2007 enlistment examination show that the category of head checked off as normal. She denied current or past recurrent frequent or severe headaches, as well as dizziness or fainting. The examiner noted no significant medical history. An August 2008 in-service examination shows the Veteran denied current or past dizziness/fainting and frequent or severe headaches. February 2009 notes specifically state there was no headache. In the last two weeks of her pregnancy in July 2009, the Veteran presented with headaches. The Veteran’s reported history of migraines without aura were also noted. In an April 2010 sea-duty examination, the Veteran responded affirmatively to current or past dizziness or fainting spells. However, she denied frequent or severe headaches. An April 2010 medical, dental and educational suitability screening shows that the Veteran denied having any neurologic conditions, to include migraine headaches. Except as reported above, overall, during the period of 2009 through October 2010, there were no neurological symptoms no dizziness, no seizures, no numbness or tingling. In an October 2010 crane/forklift operator physical examination, the Veteran reported having “dizziness, headaches or light.” April 2011 treatment notes while aboard ship show the neurological review of systems indicated no headaches. The STRs do not include a separation examination. After service, the Veteran’s June 2014 private treatment follow-up examination for hypertension and her September 2014 examination for back disorder also shows that she denied any headaches. In a September 2014 VA primary care note, a neurological review of systems shows that the Veteran again denied headaches. In December 2014, the Veteran presented to her private treatment provider with headaches symptoms beginning two months prior at 9/10 severity in pain in the right frontal-temporal region. However, in a February 2015 visit, she denied any current headaches. In the June 2015 VA examination for headaches, the Veteran’s disorder was noted as having been diagnosed as tension headaches. The June 2015 VA examiner also noted the Veteran did not take any medications for it. The June 2015 VA examiner found the Veteran had constant pulsating headache pain, with pain on the right side and lasting the entire day. However, she further found the Veteran did not have characteristic prostrating attacks of either migraine or non-migraine headache pain. By November 2015, the Veteran presented again with headache symptoms. She reported that pain was worsening to 9/10, but she was not taking medication originally prescribed for it. The treatment provider assessed her with headache. Discussion The foregoing summary of the treatment record shows that, while in service, the Veteran denied having headaches except for two instances. She first presented with headaches in the last two weeks of her pregnancy, with which and a previous pregnancy gestational hypertension had been associated. She further reported a history of migraines, but nothing in the STRs reflects this. She did not report headaches again in service for another year and three months, when, in October 2010, she checked the box for “dizziness, headaches or light.” She did not specify which one or all had manifested. As stated above, the STRs do not contain a separation examination. The latest treatment note in them appears to be when presenting on board her ship in April 2011, 14 months before separation. The neurological review of systems, based on the Veteran’s responses, indicated no headaches. After service, the Veteran did not report headaches until December 2014, when she stated they had begun only two months earlier. From this, the Board concludes that there is no competent medical evidence to show that headaches which first appeared in service during the very end stages of pregnancy were caused by active service. Moreover, there are no in-service reports of exposure to toxic substances, excessive noise or other events related to her duties which might be associated with headaches. It was approximately two and half years after the conclusion of her active service before the Veteran reported headaches to her private treatment provider, stating she had had them for only two months. The Board does not discern in this history a direct causal relationship with active service. For these reasons and based on the objective medical evidence, the Board finds the Veteran’s headaches are not caused by an event, injury or illness during active service, nor are they etiologically related to it. Consequently, service connection is not established. 3. Entitlement to service connection for back disorder. Evidence The Veteran’s September 2007 medical pre-screen interview and her October 2007 enlistment examination show that the category of spine/musculoskeletal was checked off as normal. She denied current or past recurrent back pain or problems. As already stated, the examiner noted no significant medical history. An August 2008 in-service examination shows the Veteran denied current or past recurrent back pain. February 2009 notes shows no reported or detected back pain. An April 2010 medical, dental and educational suitability screening shows that the Veteran denied having any orthopedic conditions such as chronic back, knee, joint pain, or weakness. Overall, during 2009 and through to April 2010, there were no reported musculoskeletal symptoms, no joint pain or stiffness, no muscle cramps, no swelling, and no weakness. In an April 2010 sea-duty examination, the Veteran responded affirmatively to recurrent back pain/problem. An October 2010 treatment note on board her ship shows that the Veteran presented with complaints of mid to lower back pain. However, April 2011 treatment notes aboard ship show the musculoskeletal review of systems indicated no muscle weakness, pain or limited range of motion (except for a bruised left calf). The STRs do not include a separation examination. After service, in September 2014, presented to her private treatment provider with upper-back pain, reporting pain severity at 9 out of 10. However, in a September 2014 VA primary care note, a musculoskeletal review of systems shows that the Veteran denied muscle pain or joint pain. In June 2015, the Veteran underwent a VA examination for thoracolumbar spine, in which he was diagnosed with thoracic mild spondylosis. The June 2015 VA examiner noted the Veteran’s report that she had intermittent mid-back pain two years prior with no injury and that she has had no treatment lately. Additionally, he observed that, although the Veteran also reported left mid-back pain in April 2010, “I was not able to find treatment related to her back pain in the remaining service time from [October 2010] to 2012.” Testing revealed some limited range of motion, with normal findings otherwise. The June 2015 VA examiner found imaging studies had not documented arthritis. X-rays showed mild spondylosis. He further found the Veteran’s back disorder did not impact her ability to work. He rendered a negative opinion for service connection. A February 2016 VA outpatient note states the Veteran complained of pain in the mid to upper back. A March 2016 VA physical therapy initial evaluation note states the Veteran reported pain in her lower and mid-back, present for two to three years and worsening. Discussion The above summary of the treatment record shows complaints of back pain in service only in 2010. The latest treatment note in April 2011 shows the musculoskeletal review of systems, based on the Veteran’s own reports, indicated no muscle weakness, pain or limited range of motion, other than a lower-leg bruise. As already stated, there is no separation examination in the STRs. When presenting at VA in March 2016 for physical therapy for her back, as well as at the June 2015 VA examination, the Veteran herself put the inception of her back pain at no earlier than 2013. The medical evidence offered by the record shows that in September 2014, now over two years after separation from active service, the Veteran reported upper-back pain to her private treatment provider. The Veteran reported no trauma in service to explain back pain in 2010. There are no in-service reports of it which follow. As the June 2015 VA examiner stated when explaining his opinion, “If [the Veteran’s] midback pain persisted in service, I would expect to see more treatment records in her remaining service time for [October 2010] to 2012.” The record shows no post-service treatment for back pain earlier than September 2014. Once again, there is no competent medical evidence to establish a direct connection, or nexus, between active service and a back disorder. For these reasons and based on the objective medical evidence, the Board finds the Veteran’s back disorder is not caused by an event, injury or illness during active service. Therefore, service connection is not established.   4. Entitlement to service connection for right-foot disorder. Evidence The Veteran’s September 2007 medical pre-screen interview and her October 2007 enlistment examination show that the category of lower extremities was checked off as normal. The examiner noted no significant medical history. An August 2008 in-service examination shows the Veteran denied current or past foot trouble. Overall, during 2009 through to April 2010, there were no reported musculoskeletal symptoms, no joint pain or stiffness, no muscle cramps, no swelling, and no weakness. The Veteran’s April 2010 sea-duty examination shows that she denied having any impaired use of her feet, as well as other extremities. An April 2010 medical, dental and educational suitability screening shows that the Veteran denied having any orthopedic conditions such as chronic back, knee, joint pain, or weakness. In September 2010, the Veteran’s motor vehicle operator examination shows her affirmative response to having an impairment or deformity of a limb or extremity, without further discussion of what area was involved. April 2011 treatment notes aboard ship show the musculoskeletal review of systems indicated no muscle weakness, pain or limited range of motion (except for a bruised left calf). The STRs do not include a separation examination. After service, in a September 2014 VA primary care note, a musculoskeletal review of systems shows that the Veteran denied muscle pain or joint pain. In January 2016, the Veteran presented to her private treatment provider with bilateral foot pain, reporting that six years prior a foot bone protruded, but did not cause any pain, until just recently. The treatment provider noted callous formations on top of both feet. A February 2016 VA outpatient note shows that the Veteran presented with the same complaint and report made the previous month to her private treatment provider. In March 2016, the Veteran reported for a VA podiatry consultation for x-rays and to discuss surgery for her painful right foot exostosis, bunion and hammertoes. Examination revealed the following: Hard prominence present at the level of the 1st [tarsometatarsal] joint bilaterally, right larger than left. No pain on direct palpation. Hallux valgus deformity present bilaterally, right worse than left. Right [hallux abducto valgus] - no hypermobility, tracking, no pain on palpation of bump, no limitation of motion at 1st [metatarsophalangeal]. Left [hallux abducto valgus] - no hypermobility, tracking, no pain on palpation of bump, no limitation of motion at 1st [metatarsophalangeal]. Hammertoes present 2-5 bilaterally, right worse than left, flexibile, patient relating some pain while in shoes. X-rays showed: 1. Preservation of joint spaces. 2. No acute fracture or dislocation. 3. No radiographic evidence for pes planus. After reviewing the history and physical and clinical findings, the following diagnosis was made: 1. Exostosis at 1st [tarsometatarsal] bilaterally. 2. Hallux valgus bilaterally. 3. Hammertoes 2-5 bilaterally. The VA treatment providers proposed a right-foot exostectomy and bumpectomy in August 2016. The VA treatment records do not indicate whether this surgery was performed. Discussion As shown above in the treatment record, only once in service did the Veteran report something which may have affected her right foot, when in September 2010, she responded affirmatively to having “an impairment or deformity of a limb or extremity.” All other reports in her four-year active service do not indicate the existence of a right-foot disorder. She did not report pain and seek treatment until January 2016. She stated a bone protruded six years earlier, but without pain. The STRs do not show reports, complaints, treatment, or a diagnosis of this. The above evidence further shows the Veteran planned to have surgery in August 2016, but the record does not offer confirmation that surgery took place. Similar to the claimed back disorder, there is no reported trauma in service and, similarly, there is no competent medical evidence to establish a direct connection, or nexus, between active service and a right-foot disorder. For the foregoing reasons and based on the objective medical evidence, the Board finds the Veteran’s right-foot disorder is not caused by an event, injury or illness during active service. Therefore, service connection is not established. Conclusion The Board has reviewed and carefully considered the statement accompanying the Veteran’s March 2017 VA Appeals Form 9, as well as her reports to treatment providers, as they have appeared throughout the record. These have helped the Board in understanding better the nature and development of the Veteran’s disorders and how they have affected her. Lay people are competent to report on matters observed or within their personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Therefore, the Veteran is competent to provide statements of symptoms which are observable to her senses and there is no reason to doubt her credibility. However, the Board must emphasize that the Veteran is not competent to diagnose vascular, neurological or orthopedic disorders or interpret accurately clinical findings pertaining to them, as this requires highly specialized knowledge and training. 38 C.F.R. § 3.159 (a)(1). See also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Moreover, the Board cannot render its own independent medical judgments; it does not have the expertise. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). The Board must look to the medical evidence when there are contradictory findings or statements inconsistent with the record and it must rely on clinical findings and opinions to establish the connection of current disabilities to service-related events, injuries or illnesses or determine their current level of severity. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). Based on the evidence of record, the Board has made its findings as stated above. The Board has considered the benefit-of-the-doubt doctrine; however, the Board does not perceive an approximate balance of positive and negative evidence. The preponderance of the evidence is against the claims, the doctrine is not applicable and the claims must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. MICHAEL D. LYON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD P. Franke, Associate Counsel