Citation Nr: 21061342 Decision Date: 10/01/21 Archive Date: 10/01/21 DOCKET NO. 16-24 553A DATE: October 1, 2021 REMANDED Entitlement to service connection for hypertension is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for a right knee disability is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1968 to December 1970. The Veteran served in combat operations while in Vietnam and was awarded the Silver Star and Combat Infantryman's Badge. These matters come before the Board of Veterans' Appeals (Board) on appeal from November 2014 (hypertension) and December 2014 (knees) rating decisions. The Veteran testified before the undersigned Veterans Law Judge (VLJ) at a hearing in November 2019. A transcript of that hearing is of record. These matters were previously remanded by the Board in January 2020. There has not been substantial compliance with the remand directives and the claims must be remanded again. Stegall v. West, 11 Vet. App. 268 (1998). 1. Entitlement to service connection for hypertension is remanded. The February 2020 VA medical opinion stated that that the Veteran's blood pressure at enlistment was in the hypertensive range. It is unclear to the Board if the examiner contends that the Veteran's entrance examination noted pre-existing hypertension. Upon remand, a medical opinion should be obtained that discusses whether the Veteran's hypertension pre-existed service and, if so, whether it was aggravated by service. The clinician should reconcile their findings with 38 C.F.R. § 4.104, DC 7101, Note (1), which states that hypertension for VA purposes means that the diastolic blood pressure is predominantly 90mm or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm or greater with a diastolic blood pressure of less than 90mm. The clinician should also respond to the August 2021 brief arguing that there is evidence to support causation between herbicide agent exposure and hypertension, including the address by Dr. K.K. that the Veteran's representative believes supports this contention. 2. Entitlement to service connection for a left knee disability is remanded. 3. Entitlement to service connection for a right knee disability is remanded. In the February 2020 VA examination the Veteran provided a negative nexus opinion with the rationale that the Veteran's current knee replacements are due to age related osteoarthritis, a common occurrence in the general population at the age when the Veteran received his knee replacements with similar body type. The examiner opined that it is less likely than not that any currently diagnosed knee condition was related to the Veteran's in-service history of multiple parachute jumps because review of the service medical record noted no complaints, examination, investigation, diagnosis or treatment of parachute jump injury to the left or right knee, and there are no medical records from the years immediately following service to establish chronicity. The examiner also stated that if the Veteran had had left or right knee injuries in service from parachute injuries then he would have resulted in replacements when he was younger than 55 years old. This opinion does not discuss the Veteran's competent lay testimony in the November 2019 hearing that he injured both knees during service and that his left knee has bothered him since service, but that he did not seek treatment during service because he felt doing so would be letting his team down and would delay his discharge from service. The Veteran is competent to report his experience of knee pain or trouble since service. Moreover, the examiner's assertion that knee injuries during service from parachute jumping would have resulted in replacements when the Veteran was younger than 55 years old is a conclusion that is not supported by an adequate medical rationale. Upon remand, an addendum opinion should be obtained that discusses the Veteran's competent report of left knee pain or trouble since service, provides a full rationale for any conclusions given, and also responds to the August 2021 brief stating that chronic repetitive stress trauma has been shown to be causative for degenerative joint disease. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding the etiology of the Veteran's hypertension. The clinician is to answer the following questions: (a.) Does the August 1967 entrance examination note a disability of hypertension? The clinician should reconcile their answer with VA regulation 38 C.F.R. § 4.104, DC 7101, Note (1), which states that hypertension means that the diastolic blood pressure is predominantly 90mm or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm or greater with a diastolic blood pressure of less than 90mm. (b.) If the August 1967 entrance examination does note a disability of hypertension, did the Veteran's hypertension, which existed prior to service, at least as likely as not (50 percent or greater probability) increase in severity during service? (c.) If the Veteran had preexisting hypertension that increased in severity during service, was the increase in severity clearly and unmistakably (undebatable) due to the natural progress of the disease? (d.) If the Veteran's August 1967 entrance examination does not note a disability of hypertension, is it at least as likely as not (50 percent or greater probability) that the Veteran's current hypertension is related to exposure to herbicide agents during service? In answering this question, the examiner must specifically discuss the following: (i) The August 2021 brief in which the Veteran's representative argues that there is evidence of a causative association between exposure to herbicide agents and hypertension, and cites remarks from a Dr. K.K. in support of that contention. (ii) The National Academy of Sciences (NAS) Veterans and Agent Orange Updates, to include in 2018, which stated that there was "sufficient" evidence of an association between hypertension and herbicide exposure. In addition, the examiner must discuss whether they find the NAS Updates to be persuasive and weigh the relative risks presented by the Veteran's presumed Agent Orange exposure and other relevant factors. The examiner is advised that, although VA has not determined that hypertension qualifies for presumptive service connection based on herbicide exposure, this does not preclude a nexus to service. Instead, the examiner must consider all pertinent evidence, and offer an opinion as to whether the Veteran's hypertension is due to such exposure. Each opinion offered must be supported by a complete rationale. 2. Obtain an addendum opinion from an appropriate clinician regarding the etiology of the Veteran's bilateral knee disabilities. The clinician must respond to the following questions: (a.) Is it at least as likely as not (50 percent or greater probability) that the Veteran's left knee disability is related to an in-service injury of the left knee when parachuting out of a helicopter during a combat mission? The clinician must respond to the Veteran's November 2019 hearing testimony that his left knee bothered him during and since service, but that he did not seek treatment because he did not want to let his team down, as well as the August 2021 brief citing an article in support of an argument that chronic repetitive stress trauma, such as parachute jumping, has been shown to be causative for degenerative joint disease. (b.) Is it at least as likely as not (50 percent or greater probability) that the Veteran's right knee disability is related to an in-service parachute jumping injury? The clinician must respond to the Veteran's November 2019 hearing testimony in which the Veteran reported that he did not seek treatment for the right knee injury because he was near separation and believed that if he sought treatment his discharge would be delayed. The clinician must also discuss the August 2021 brief citing an article in support of an argument that chronic repetitive stress trauma, such as parachute jumping, has been shown to be causative for degenerative joint disease. Each opinion offered must be supported by a complete rationale. It is not sufficient to state that if the Veteran had suffered knee injuries in service, he would have had his knee replacement surgeries earlier than age 55 without setting forth a clear medical rationale explaining this conclusion and taking into consideration the possibility that the Veteran experienced knee pain well before he had knee replacement surgery. M.E. Larkin Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Budd, 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.