Citation Nr: 20032452 Decision Date: 05/08/20 Archive Date: 05/08/20 DOCKET NO. 97-20 514A DATE: May 8, 2020 ORDER Entitlement to service connection for lumbar strain with degenerative changes (hereinafter “low back disability”) is granted. Entitlement to service connection for hypertension, to include as due to service-connected posttraumatic stress disorder (PTSD) is granted. REMANDED Entitlement to service connection for the residuals of a left rotator cuff injury, to include as being secondary to a low back disability is remanded. FINDINGS OF FACT 1. The Veteran has experienced back pain related to arthritis since his separation from service. 2. The Veteran’s hypertension is proximately due to his service-connected PTSD. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for lumbar strain with mild degenerative changes have been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for entitlement to service connection for hypertension, to include as due to service-connected PTSD have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from February 1963 to April 1965, with over a year of prior unverified active military service, to include periods of active duty for training (ACDUTRA). This matter came before the Board of Veterans’ Appeals (Board) on appeal from rating decisions issued in April 1997 (low back and left rotator cuff) and April 2008 (hypertension) by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge in February 2010. Additionally, in August 2002, the Veteran testified before another Veterans Law Judge who has since left her employment at the Board. A transcript of each hearing has been included in the claims file and has been reviewed. The claims on appeal have been subject to multiple prior Board decisions and remands and multiple prior remands of the U.S. Court of Appeals for Veterans Claims. Most recently, in April 2018, the Board remanded the claims for additional medical inquiry and commentary. The claims are again before the Board for appellate review. The Board finds substantial compliance with prior remand directives. Service Connection 1. Entitlement to service connection for a low back disability. The Veteran contends that his low back disability is related to service. Certain chronic diseases will be presumed related to service if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service, with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). The Veteran has a current diagnosis of lumbar strain with degenerative changes as evidenced by the February 2007 VA spine examination. Arthritis is an enumerated condition under 38 C.F.R. § 3.309(a); Walker, 708 F.3d 1331. Service treatment records show the Veteran complained of back aches in March 1965 during active service. The July 1965 VA examination conducted two months after separation from service, notes the Veteran had intermittent low back ache occurring once a week since the report of back pain in March 1965. Post service private treatment records show that he continued to complain of and sought treatment for the same symptoms following service and reveal the Veteran suffered from additional injury to his low back due to an automobile accident in 1966. Additionally, the Board finds that the Veteran continued to experience the same symptoms from March 1965 to the present. Here, the Board finds the Veteran is competent to report that he experienced symptoms of low back pain during and immediately following service. The Veteran has submitted several statements documenting his reports of pain in his low back and indicating possible origins of injury, to include having to lift and carry heavy ammunition shells and load dummies up ladders in rough seas. He has also submitted several statements in 1965 from family members, friends and fellow service members who described the Veteran’s complaints of back pain and origins of injury during service. Moreover, the Veteran has consistently contended his low back pain is related to service since he filed his claim in May 1965. The Board finds these statements are credible and entitled to probative weight, as they are internally consistent and consistent with other evidence of record, which shows that these symptoms were attributable to the Veteran’s lumbar strain with degenerative changes. Evidence against the Veteran’s claim includes the September 2019 VA medical opinion which lists the Veteran’s reports of low back pain and injuries to the Veteran’s back from 1965 to the 1980s. The examiner opined that the it is less likely than not that any disability diagnosed since October 1996 relates to the injuries the Veteran experienced during service. The Board assigns little probative value to this opinion because even though the examiner lists the pertinent medical evidence concerning the Veteran’s low back disability during and since service the opinion did not adequately address how this evidence weighed into the examiner’s opinion. Additionally, the examiner did not consider the numerous statements made by the Veteran, his family members, friends and fellow service members which document the Veteran’s reports of back pain during and since service. Thus, based on these findings the Board has resolved reasonable doubt in the Veteran’s favor and the claim is granted. 2. Entitlement to service connection for hypertension, to include as due to service-connected PTSD. The Veteran contends his hypertension is related to his service-connected PTSD. The April 2008 VA examination show the Veteran has a current disability of hypertension, and the December 2007 VA psychiatrist Dr. S. M. opined that it is likely that the Veteran’s hypertension is related at least in part to his chronic PTSD. The evidence against the Veteran’s claim includes the August 2016, January 2017, May 2017 VA medical opinions which all recite that the Veteran PTSD may cause a brief transient rise in blood pressure, but it would not result in sustained hypertension. The Board affords these examinations no probative value as they do not provide an adequate rationale as to the opinions rendered as they all offer conclusory statements. Additionally, none of these opinions adequately address whether the Veteran’s service-connected PTSD has aggravated his hypertension as they all suggest that PTSD may cause brief transient rise in blood pressure. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran’s current hypertension is proximately due to his service-connected PTSD. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for hypertension is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102.” REASONS FOR REMAND Entitlement to service connection for the residuals of a left rotator cuff injury, to include as being secondary to a low back disability is remanded. The Board finds remand necessary to obtain an addendum opinion. Per this decision the Board has granted service connection for a low back disability and the Veteran has asserted throughout the record that his left rotator cuff injury is due to or aggravated by his low back disability. Additionally, the Veteran has asserted his disability is due to lifting and carrying heavy supplies up and down ladders during rough seas. The opinions of record to include the December 2017, and the August 2015 do not adequately address the Veteran’s contentions on a direct and secondary basis. Thus, an opinion is needed to determine if the Veteran’s residuals of a left rotator cuff injury are related to service or proximately due to or aggravated by his low back disability. The matter is REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s left rotator cuff injury is at least as likely as not related to lifting and carrying heavy ammunitions and load dummies up ladders during rough seas while at sea or is proximately due to service-connected disability or aggravated beyond its natural progression by service-connected disability. The examiner must also address the Veteran’s statements of possible origins of injury to the Veteran’s left rotator cuff. All opinions provided must be thoroughly explained, and a complete and detailed rationale for any conclusions reached should be provided (a bare conclusory statement will be deemed inadequate). The examiner is reminded that the term “as likely as not” does not mean within the realm of possibility,” but rather that the evidence of record is so evenly divided that, in the examiner’s expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it 2. After the completion of any action deemed appropriate in addition to that requested above, the Veteran’s claim should be readjudicated. If the benefit sought remains denied, the Veteran should be provided another Supplemental Statement of the Case (SSOC). C. TRUEBA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. McDuffie, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.