Citation Nr: 1806369 Decision Date: 02/01/18 Archive Date: 02/14/18 DOCKET NO. 13-17 262 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUES 1. Entitlement to service connection for hypertension, to include as due to herbicide agent exposure. 2. Entitlement to service connection for a right shoulder disability, to include impingement syndrome and osteoarthritis, and to include as secondary to a service-connected cervical spine disability. 3. Entitlement to service connection of a left shoulder disability to include impingement syndrome and osteoarthritis, and to include as secondary to a service-connected cervical spine disability. REPRESENTATION Appellant represented by: California Department of Veterans Affairs WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD E. Alexander Neff, Associate Counsel INTRODUCTION The Veteran served on active duty in the Navy from June 1974 to May 1980, with various periods of active duty and inactive duty service in the Naval Reserves from August 1980 to November 1994. His awards and decorations included a National Defense Service Medal. The Board sincerely thanks him for his service to his country. This case comes before the Board of Veterans' Appeals (Board) on appeal from September 2009 and May 2013 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Oakland, California. The September 2009 rating decision denied the Veteran's claim for service connection for hypertension, and the May 2013 rating decision denied service connection for the right and left shoulders. In September 2017, the Veteran testified at a Video Conference hearing before the undersigned Veterans Law Judge; a transcript of which is included in the record. FINDINGS OF FACT 1. The Veteran's hypertension is not related to any injury or disease incurred during his active duty military service, and was not manifested with one year after the Veteran's separation from active duty service in May 1980. 2. The Veteran's bilateral shoulder impingement syndrome and bilateral acromioclavicular (AC) joint osteoarthritis is related to service and/or a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2017). 2. The criteria for service connection for a right shoulder disability, to include impingement syndrome and AC joint osteoarthritis, are met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. 3. The criteria for service connection for a left shoulder disability, to include impingement syndrome and AC joint osteoarthritis, are met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Legal Criteria A. Service Connection To substantiate a claim of service connection, there must be evidence of: (1) a current disability (for which service connection is sought); (2) incurrence or aggravation of a disease or injury in service; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-1167 (Fed. Cir. 2004). The determination as to whether these requirements are met is based on an analysis of all evidence of record and an evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). Service connection may be granted for disabilities due to disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 1131; 38 C.F.R. § 3.303. Service connection may also be granted for any disease initially diagnosed after discharge when the evidence establishes that disability was incurred in service. 38 C.F.R. § 3.303(d). Certain chronic disabilities, such as hypertension and arthritis, 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. Alternatively, a nexus to service may be presumed where there is continuity of symptomatology since service. Walker v. Shinseki, 708 F.3d 1331, 1338-40 (Fed. Cir. 2013). Continuity of symptomatology after discharge is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303 (b). The theory of continuity of symptomatology under 38 C.F.R. § 3.303(b) does not apply to any condition that has not been recognized as chronic under 38 C.F.R. § 3.309(a). Walker, 708 F.3d 1331. Active service includes any period of ACDUTRA during which the individual was disabled from a disease or an injury incurred in the line of duty, or a period of inactive duty training (INACDUTRA) during which the veteran was disabled from an injury incurred in the line of duty or from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident occurring during such training. 38 U.S.C.A. § 101(24); 38 C.F.R. § 3.6(a). In other words, with respect to Reserve service, service connection may only be granted for disability resulting from disease or injury incurred or aggravated while performing ACDUTRA, or an injury incurred or aggravated while performing INACDUTRA. Service connection is generally not legally merited when a disability incurred on inactive duty training results from a disease process. See Brooks v. Brown, 5 Vet. App. 484, 487 (1993). ACDUTRA includes full-time duty in the Armed Forces performed by the Reserves for training purposes. 38 U.S.C.A. § 101(22); 38 C.F.R. § 3.6(c). INACDUTRA includes duty, other than full-time duty, prescribed for the Reserves. 38 U.S.C.A. § 101(23)(A). Reserves include the National Guard. 38 U.S.C.A. § 101(26), (27). Certain evidentiary presumptions - such as the presumption of sound condition at entrance to service, the presumption of aggravation during service of preexisting diseases or injuries which undergo an increase in severity during service, and the presumption of service incurrence for certain diseases, which manifest themselves to a degree of disability of 10 percent or more within a specified time after separation from service - are provided by law to assist veterans in establishing service connection for a disability or disabilities. 38 U.S.C.A. §§ 101, 1112; 38 C.F.R. §§ 3.304(b), 3.306, 3.307, 3.309. However, the advantages of these evidentiary presumptions do not extend to those who claim service connection based on a period of ACDUTRA or INACDUTRA. Paulson v. Brown, 7 Vet. App. 466, 470-71 (1995) (noting that the Board did not err in not applying presumptions of sound condition and aggravation to appellant's claim where he served only on ACDUTRA and had not established any service-connected disabilities from that period); McManaway v. West, 13 Vet. App. 60, 67 (citing Paulson, 7 Vet. App. at 469-70, for the proposition that "if a claim relates to period of [ACDUTRA], a disability must have manifested itself during that period; otherwise, the period does not qualify as active military service and claimant does not achieve veteran status for purposes of that claim."). The Board notes that the Veteran served on active duty the in Navy during the Vietnam War era, and generally alleged in August 2010 that his hypertension was related to herbicide agent exposure. The Board additionally notes that service in the Republic of Vietnam includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam, that is, within the land borders, including the inland waters, of Vietnam. 38 C.F.R. § 3.307(a)(6)(iii); Haas v. Nicholson, 20 Vet. App. 257 (2006), rev'd sub nom. Haas v. Peake, 525 F.3d 1168 (Fed. Cir. 2008), cert. denied, 77 U.S.L.W. 3267 (Jan. 21, 2009) (No. 08-525) (upholding VA's interpretation of 38 C.F.R. § 3.307(a)(6)(iii) as requiring a service member's presence on the landmass or inland waters of Vietnam in order to benefit from the regulation's presumption); see also Gray v. McDonald, 27 Vet. App. 313, 325 (2015). The Board notes that the Veteran has not asserted that he had visited Vietnam or its inland waterways during service, or has otherwise provided how he may have otherwise had contact with any herbicide agent. VA law is clear that the duty to assist is not a one-way street. Wood v. Derwinski, 1 Vet. App. 190, 192 (1991). As such, the August 2010 statement alone is not sufficient to demonstrate that the Veteran was exposed to any herbicide agents in service. Regardless, the Veteran's service records demonstrated that he served on the U.S.S. Wiltsie starting in May 1974, on the U.S.S. Oriskany from September 1974 until he was transferred to the U.S.S. Mars in November 1976. It is noted that VA has promulgated a listing of the Navy ships (including "blue water" ships) associated with service in Vietnam and, hence, exposure to herbicide agents. See Navy and Coast Guard Ships Associated with Service in Vietnam and Exposure to Herbicide Agents (November 1, 2017); see also VA Manual M21-1, Part IV, Subpart ii, Chapter 1, Section H, Part 2.d. The U.S.S. Wiltsie and the U.S.S. Oriskany are not included in that list. As such, the Board finds that herbicide agent exposure has not been demonstrated either by presumption or by fact. 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. However, competent medical evidence is necessary where the determinative question is one requiring medical knowledge. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). 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 also include statements contained 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. When there is an approximate balance of positive and negative evidence regarding the merits of an issue, the benefit of the doubt shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. If the preponderance of the evidence is against the claim, the claim is to be denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The Board notes that it has reviewed all of the evidence in the record, 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 of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claims being decided. II. Hypertension A. Factual Background and Analysis In the May 1974 enlistment examination, the Veteran was found to be clinically normal. In an report of medical history from this time, he marked "no" for high or low blood pressure. In the May 1977 reenlistment examination, the Veteran was found to have normal vascular system and heart. In a September 1979 STR, the Veteran was noted to be five pounds overweight. In the April 1980 discharge examination, the Veteran's vascular system and heart was found to be normal. In a January 1981 ACDUTRA orders, it was noted that the Veteran was physically qualified for ACDUTRA and that he was examined and qualified for release. In a June 1987 report of medical examination, made during a period of ACDUTRA, the Veteran's vascular system and heart was found to be normal. In an August 1990 private medical record, the Veteran complained of chest pain. He was not found to have hypertension, and was diagnosed with non-cardiac pain. In an April 1991 private medical record, the Veteran complained of light headedness. He reported that he had a drilled in the Reserves the prior weekend, and thought that his blood pressure had been high. The clincian's impression was job-related stress. In a July 1991 STR related to his Reserve service, the Veteran was noted as having been evaluated at a private clinic for possible hypertension. In a report of medical examination, noted to have been reviewed in March 1993, related to his Reserve service, the Veteran was found to be overfat and to have possible hypertension. His blood pressure was measured as 124/96. In an August 2004 VA medical record, it was noted that the Veteran took hypertension medication. In an August 2007 private medical record, the Veteran was noted to have essential hypertension. In November 2007, he was diagnosed with chronic hypertension. In an undated statement, received by VA in August 2009, the Veteran reported that in September 1979 he reported to sick call for "overweight problems." There he was told to lose five pounds. In July 1991, while on Naval Reserve duty, he was diagnosed as overweight and with possible hypertension. These symptoms "slowly but surely" affected the Veteran's health over time. In June 2007, he was diagnosed, in part, with hypertension. In August 2010, the Veteran claimed that his hypertension was secondary to herbicide agent exposure, and that it was "discovered" in 1990. In his June 2013 VA Form 9, the Veteran claimed that his hypertension began or was aggravated by military service. He stated that his symptoms first began in March 1993, when he was diagnosed as "over fat" and with "possible hypertension." In a January 2017 statement, the Veteran reported that in March 1993, during a period of INACDUTRA, he reported to sick call and was told that his blood pressure was high, 194/96, and he went home. The following day, he underwent a physical in preparation for ACDUTRA, and his blood pressure was the same as before. The clinician diagnosed him with possible hypertension, and the Veteran claimed that he has had hypertension since. At the September 2017 hearing, the Veteran testified that he did not receive hypertension treatment during his active duty Naval service. During his separation examination from his initial period of active duty service, the examining clinician advised the Veteran that he had a weight problem. The clinician recommended that the Veteran correct this, or he may have high blood pressure in the immediate future. The Veteran reported that he was not diagnosed with hypertension within one year of separation of his initial period of active duty service. He recalled that on one occasion during Reserve duty was told that he had high blood pressure. He reported that he experienced elevated blood pressure while he was in the Reserves. He testified that he was both diagnosed with possible hypertension/hypertension during a period of INACDUTRA, which he alluded occurred in March 1993. Upon consideration of the above, the Board finds that the preponderance of the evidence is against finding that the Veteran's hypertension is related to service. As such, service connection is not warranted. As an initial matter, the Board notes that VA is obliged to provide a VA examination or obtain a medical opinion when: (1) there is competent evidence that the Veteran has a current disability or persistent or recurrent symptoms of disability; (2) there is evidence establishing that the Veteran suffered an event, injury or disease in service or has a disease or symptoms of a disease within a specified presumptive period; (3) the evidence indicates that the current disability or symptoms may be associated with service or a service-connected disability; but (4) there is insufficient medical evidence on file to decide the claim. McLendon v. Nicholson, 20 Vet. App. 79, 81-82 (2006); see also 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4). In both McLendon and Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010), the Court of Appeals for Veterans Claims and the U.S. Court of Appeals for the Federal Circuit (Federal Circuit Court) clarified that, when determining whether a VA examination and opinion are required under 38 U.S.C. § 5103A(d)(2), the law requires competent evidence of a disability or persistent or recurrent symptoms of a disability, but does not require competent evidence of a nexus, only that the evidence indicates an association between the disability and service or a service-connected disability. See also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010) (medically competent evidence is not required in every case to "indicate" that the claimant's disability "may be associated" with his service). The Veteran has not been provided a VA examination for his service-connection claim. However, the Board concludes that an examination and medical opinion are not needed to fairly decide this claim. This is because the record contains no competent and credible evidence that indicates that the Veteran was exposed to herbicide agents during service, or that indicates that he was diagnosed with hypertension during a period of active duty, to include ACDUTRA. See McLendon, 20 Vet. App. at 81-82 (2006). There equally is no competent and credible evidence suggesting that his hypertension may be etiologically associated with a period of active duty service, to include ACDUTRA. The Board recognizes that the Court in McLendon held that the third element establishes a "low threshold," and that a VA examination can be required based on medical evidence merely suggesting a nexus, but that is too equivocal or lacking in specificity to support a decision on the merits. However, even considering this low threshold, none of the credible evidence of record contains any indication that the Veteran's hypertension might be associated with any in-service event, injury, or disease that occurred during a period of active duty. The record only contains the Veteran's lay statements, which are not substantiated by the competent and credible medical record, that his hypertension is related to service. Therefore, a remand in order to obtain an opinion regarding the issue of causation is not required under McLendon. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (finding that further development would serve no useful purpose when it would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran). Accordingly, the Board finds that VA's duty to assist has been met. 38 C.F.R. § 3.159(c)(4); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board additionally notes that the Veteran has made several inconsistent statements regarding when he was diagnosed with hypertension, and the symptoms related to same, which impact the credibility of his statements regarding the origins of his hypertension. Notably, the Veteran has stated that his hypertension was discovered in 1990, and that he was diagnosed with same in June 2007. He also initially testified that that he was diagnosed with hypertension in March 1993, but then advised that it was instead possible hypertension. Upon review of the record, the Board observes that clinical records reflect hypertension medication was prescribed in 2004 and the Veteran was diagnosed with hypertension in 2007. Further, the Board notes that in January 2017 the Veteran claimed that his blood pressure was measured at 194/96 at the March 1993 Reserve service examination; however, review of a the report of medical examination from this time demonstrates that the Veteran's blood pressure was 124/96. As such, the Board finds that this statement lacks credibility as it is inconsistent with the contemporaneous medical evidence. Further, in a statement received in August 2009, the Veteran reported that in July 1991, while on Naval Reserve duty, he was diagnosed as overweight and with possible hypertension. Review of STRs from that time show that the Veteran had reported to a military clinician that he was seen by his private clinician for possible hypertension. As such, the Board finds that this statement also lacks credibility as it is not supported by the contemporaneous medical evidence. Service connection for hypertension is not warranted on the basis that it manifested during a period of active duty, and persisted. Notably the Veteran testified that he was not treated with, nor diagnosed with, hypertension during a period of active duty service. The STRs likewise reflect no such diagnosis during active duty The Veteran's hypertension was also not shown to have been manifested within the first post-service year from his release of active duty in May 1980, thus the chronic disease presumptive provisions of 38 U.S.C.A. §§ 1112, 1137; 38 C.F.R. §§ 3.307, 3.309 do not apply. Service connection is also not warranted on the basis of continuity of symptomatology under 38 C.F.R. § 3.303(b) as the Veteran does not report and the evidence does not show continuous hypertension symptoms since service. In fact, a 2004 medical record noted that the Veteran stopped taking hypertension medication because he felt better, indicating his symptoms had resolved, which does not support a finding of continuity. While the Veteran is competent to describe lay observable symptoms related to hypertension, to the extent that he is asserting that there is a continuity of symptomatology, or other theory of nexus, the Board does not find his statements to be competent evidence. This is because the specific issues in this case (whether the Veteran has hypertension that is related to active duty service) fall outside of the realm of common knowledge of a lay person. See Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons are not competent to diagnose cancer). Notably, the Veteran has not been shown to have the necessary education, training, or experience, and is not competent to opine as to the diagnosis and etiology of his hypertension. See Jandreau, 492 F.3d 1372 (Fed. Cir. 2007). Thus, the Veteran's statements do not constitute competent evidence in support of his claim. Additionally, the competent and credible medial evidence does not suggest or relate the Veteran's hypertension back to a period of active duty service. As such, the preponderance of the evidence is against the claim of service connection for hypertension based on continuity of symptomatology. The Board acknowledges that the Veteran has a current hypertension disability. However, the medical record does not demonstrate that the Veteran first exhibited signs or symptoms of, or was diagnosed with, hypertension during a period of active duty service or that hypertension was manifest to a compensable degree within one year of a period of active duty service. Notably, a finding of "possible hypertension" on a 1993 Reserve examination in itself is not a diagnosis of hypertension, particularly as an April 1991 service record showed that the Veteran had been evaluated privately for possible hypertension. The record is also silent as to any post-service medical provider relating the Veteran's hypertension to his active duty service. Upon review of record, the Board finds that the competent, credible, probative, and persuasive evidence fails to demonstrate that the Veteran's hypertension is related to a period of active military service, or that it was incurred in a period of same. To the extent that the Veteran has argued that his hypertension was aggravated during a period of ACDUTRA or INACDUTRA, this claim must fail as this presumption is not available for these periods of service. As such, service connection for hypertension is not warranted. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim of service connection for hypertension; therefore, the benefit of the doubt rule does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. §3.102. The appeal must be denied. III. Right and Left Shoulder In a July 1994 STR, while on ACDUTRA, the Veteran was involved in a motor vehicle accident. He was noted to have tenderness to palpation from the neck and across the shoulder along the line of the trapezius muscle. In June 2010, the Veteran was diagnosed with mild degenerative joint disease of the left AC joint. In July 2010, the Veteran was diagnosed with osteoarthritis of the right AC joint. In an August 2010 statement, the Veteran related his right and left shoulder disabilities to his service-connected neck disability. In a November 2010 private medical opinion, the clinician reported that the Veteran had bilateral shoulder impingement syndrome that was the result of compensating for his cervical and lumbar conditions. The Veteran is service-connected for cervical and lumbar spine disabilities. In the June 2011 VA shoulder examination, the Veteran was noted to have degenerative joint disease of the bilateral acromioclavicular joints. The examiner opined that the Veteran's July 1994 cervical spine injuries did not cause the AC joint disease. In a February 2017 private medical opinion, upon review of available medical records and a medical examination, the clincian's impression was that the Veteran's bilateral shoulder pain likely had a multifactorial etiology. Possible contributors, in part, included the cervical spine and AC joints. It was noted that the Veteran had chronic shoulder pain due to injuries sustained in the July 1994 motor vehicle accident. The clinician opined that it was more likely than not that the Veteran's shoulder pain was a secondary condition related to this motor vehicle collision. In a March 2017 military medical record, the Veteran was noted with shoulder pain that was multifactorial in nature with a strong osteoarthritis component. In an October 2017 private medical opinion, the Veteran was noted to have bilateral impingement syndrome with associated biceps tendonitis, and bilateral degenerative changes of AC joints. Regarding the Veteran's AC joints, the clinician observed that "typically" radiographic changes of the AC joint did not clinically correlate with the Veteran's symptoms. It was observed that, generally, impingement syndrome could be caused by a motor vehicle accident, especially like the kind the Veteran experienced in 1994. The clinician noted that he had a hard time directly connecting a diagnosis of impingement syndrome that "showed up" 19 years after a motor vehicle accident. However, he opined that there was a reasonable medical probability the Veteran's current bilateral impingement syndrome was more likely than not related to the July 1994 motor vehicle accident. Upon consideration of the foregoing, the Board finds that weight of the evidence is in favor of the Veteran's claims for entitlement to service connection of the right and left shoulders. The Board observes that the November 2010 and October 2017 private medical opinions found that there was a positive relationship between the Veteran's July 1994 ACDUTRA motor vehicle accident, or the service-connected disabilities related to same, and his bilateral impingement syndrome. These opinions were made upon a review of the record, were factually accurate, and provided adequate reasons and basis in support of the conclusions. Thus, the Board finds that these opinions are competent, credible, probative, and dispositive as to the Veteran's claim for bilateral shoulder impingement. As such, the Board finds that service connection is warranted for right and left shoulder impingement syndrome. The Board notes that during the course of the appeal the Veteran was diagnosed with bilateral AC joint osteoarthritis. The June 2011 VA examiner opined that it was less likely than not that the Veteran's bilateral AC joint degenerative joint disease was related to his service-connected cervical spine disability. However, the February 2017 private medical opinion provider noted that the Veteran's bilateral shoulder pain likely had a multifactorial etiology, which included the cervical spine and the bilateral AC joints. Notably, the competent and credible medical record contains several occasions that indicated that the Veteran's shoulder pain was multifactorial in nature. Further, there are several instances where the Veteran's bilateral shoulder pain was related to the July 1994 motor vehicle accident, or its associated service-connected disabilities. Giving the Veteran the benefit of the doubt, the Board finds that weight of the evidence is at least in equipoise that the Veteran's bilateral AC joint arthritis has a positive relationship to the July 1994 motor vehicle accident and/or its associated service-connected disabilities. As such, the Board finds that service connection for bilateral shoulder AC joint osteoarthritis is warranted. In summation, the weight of the evidence is in favor of granting service connection for bilateral impingement syndrome and AC joint osteoarthritis. In so granting these claims, the Board notes that all manifestations of the Veteran's right and left shoulder symptoms have been considered and accounted for. ORDER Entitlement to service connection for hypertension is denied. Entitlement to service connection for a right shoulder disability, to include impingement syndrome and osteoarthritis, is granted. Entitlement to service connection for a left shoulder disability, to include impingement syndrome and osteoarthritis, is granted. ______________________________________________ M. C. GRAHAM Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs