Citation Nr: 21072316 Decision Date: 12/02/21 Archive Date: 12/02/21 DOCKET NO. 16-53 295A DATE: December 2, 2021 ORDER A 70 percent rating for posttraumatic stress disorder (PTSD) for the period on appeal prior to March 1, 2021, is granted; a rating in excess of 70 percent is denied at all times relevant to the decision. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is denied. Entitlement to service connection for hypertension is denied. Entitlement to service connection for a cervical spine disorder is denied. Entitlement to service connection for a left upper extremity disorder, to include any musculoskeletal disorder associated with the left shoulder and/or neurological disorders is denied. Entitlement to service connection for a right upper extremity disorder, to include any musculoskeletal disorder associated with the right shoulder and/or neurological disorders is denied. Entitlement to service connection for a left knee disorder is denied. Entitlement to service connection for a right knee disorder is denied. Entitlement to service connection for migraine headaches is granted. FINDINGS OF FACT 1. The severity, frequency, and duration of the Veteran's PTSD more closely approximate occupational and social impairment with deficiencies in most areas for the period on appeal prior to March 1, 2021; the severity, frequency, and duration of the Veteran's symptoms do not more closely approximate total occupational and social impairment at any time. 2. The preponderance of the evidence is against finding that the Veteran is unable to secure and follow a substantially gainful occupation as a result of his service-connected disabilities. 3. The Veteran's hypertension was not manifest in service nor did it manifest within one year of separation from service. The disability is not otherwise related to service and is unrelated (caused or aggravated) to service-connected disease or injury. 4. The Veteran's cervical spine disability was not manifest in service nor did arthritis or degenerative disc disease (other organic diseases of the nervous system) of the cervical spine manifest within one year of separation from service. The disability is not otherwise related to service. 5. The Veteran's left upper extremity disorder, to include any musculoskeletal disorder associated with the left shoulder and/or neurological disorders was not manifest in service nor did it manifest within one year of separation from service. The disability is not otherwise related to service and is unrelated (caused or aggravated) to service-connected disease or injury. 6. A right upper extremity disorder, to include any musculoskeletal disorder associated with the right shoulder and/or neurological disorders was not manifest in service nor did it manifest within one year of separation from service. The disability is not otherwise related to service and is unrelated (caused or aggravated) to service-connected disease or injury. 7. The Veteran's left knee disability was not manifest in service nor did arthritis of the knee manifest within one year of separation from service. The disability is not otherwise related to service. 8. The Veteran's right knee disability was not manifest in service nor did arthritis of the knee manifest within one year of separation from service. The disability is not otherwise related to service. 9. The Veteran's migraine headaches are attributable to service. CONCLUSIONS OF LAW 1. The criteria for a 70 percent rating for PTSD are met at all times prior to March 1, 2021; a disability rating in excess of 70 percent are not met or approximated at any time. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9411. 2. The criteria for TDIU are not met. 38 U.S.C. § 1155; 38 C.F.R. § 4.16. 3. The criteria for service connection for hypertension are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 4. The criteria for service connection for cervical spine disability are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 5. The criteria for service connection for left upper extremity disorder, to include any musculoskeletal disorder associated with the left shoulder and/or neurological disorders are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 6. The criteria for service connection for right upper extremity disorder, to include any musculoskeletal disorder associated with the right shoulder and/or neurological disorders are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 7. The criteria for service connection for left knee disability are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 8. The criteria for service connection for right knee disability are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 9. Migraine headaches were incurred in wartime service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1984 to October 2000. He appeals multiple VA rating decisions. These matters were remanded by the Board in a detailed September 2019 decision, and they have been returned for appellate review. Increased Rating for PTSD and TDIU The Veteran contends that his PTSD is more disabling than the current ratings reflect. The Board remanded the matter in September 2019 to obtain an adequate examination record, deeming the 2015 VA examination inadequate. Also, the Board found that a TDIU appeal stems from the PTSD claim for increased rating. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Increased rating for PTSD In a March 2010 rating decision, the RO granted service connection for this disability and assigned a 30 percent rating effective from January 21, 2010. The November 2012 rating decision that denied a rating in excess of 30 percent cites an August 24, 2011 statement as the date of claim for increase. In a March 2021 rating decision, a 70 percent rating was granted for PTSD effective March 1, 2021. Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity resulting from disability. Separate diagnostic codes (DCs) identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for the higher evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. Separate ratings may be assigned for separate periods of time based on the facts found. This practice is known as "staged" ratings." Fenderson v. West, 12 Vet. App. 119, 126-127 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran has argued throughout the appeal, prior to the grant of 70 percent, that the disability warrants higher than a 30 percent rating. As noted in the 2019 Board remand, the 2015 VA mental health examination was inadequate for rating purposes. The VA examination prior to that time, dated in August 2012, reflects a report of suicidal thoughts and an assessment of severe symptoms on psychological testing, despite an indication that there was only occupational and social impairment consistent with a 30 percent rating (occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks). Upon review of the evidence, with specific emphasis on the March 2021 VA examination and the actual reported symptoms in treatment records throughout the appeal period, the Board finds that the Veteran's PTSD warrants a rating of 70 percent for the entire period on appeal. However, it finds that the preponderance of the evidence is against a rating in excess of 70 percent at any time relevant to the claim. The Veteran's rating is assigned under Diagnostic Code 9411. 38 C.F.R. § 4.130. The disability is rated using the General Rating Formula for Mental Disorders (General Formula). Under that Formula: A 70 percent disability rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. VA must engage in a holistic analysis that assesses the severity, frequency, and duration of the signs and symptoms of the psychiatric disability; quantifies the level of occupational and social impairment caused by those symptoms; and assigns an evaluation that most nearly approximates the level of occupational and social impairment. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017). Relevant to this discussion is the April 2013 Notice of Disagreement authored by the Veteran's now ex-representative which indicated that Veteran did not understand why VA found his PTSD had not increased in severity. He reported he was engaged in counseling due to problems with his temper, mood and suicidal ideation. He reported medication for these problems. He reported difficulties with his manager and co-workers and noted he had been threatened with being fired 5 - 6 times over the last year. He reported difficulties in his home life as well due to arguing and fighting. He reportedly avoids fighting by leaving the home. He has problems with decreased concentration, memory focus and depression. Treatment records are not inconsistent with this characterization of the Veteran's PTSD symptoms. Thereafter, we have the inadequate 2015 VA examination, followed by the March 2021 VA examination which indeed supports a 70 percent rating. The 2021 examiner found occupational and social impairment with deficiencies in most areas and noted impaired impulse control, such as unprovoked irritability with periods of violence. There was difficulty in establishing and maintaining effective work and social relationships. He denied current suicidal/homicidal thoughts, intentions, or plans. Since the 2015 examination, he reported he has been "in and out" of the car business and was currently working at a car dealership making calls to customers. He reported he has no work friends because they think he has "an attitude problem." Treatment records throughout the appeal period suggest a consistent level of impairment due to PTSD. There does not appear to be any assessment of worsening as of March 2021. The records consistently show the anger and mood swings with occasional references to suicidal ideation. For example, in a September 2020 group, he experienced irritability and passive suicidal ideation such as asking himself, "Why am I here?" He left the group that day and did not rejoin that day. There are five buddy statements dated in March 2021 that speak to the Veteran's struggles with anger, mood swings and anxiety related to his PTSD both at work and at home throughout the appeal period. Resolving reasonable doubt in the Veteran's favor, the severity, frequency, and duration of the Veteran's disorder more closely approximate occupational and social impairment with deficiencies in most areas at all times throughout the appeal period. We find the March 2021 VA examiner's assessment to be of great probative weight as it is well-supported and consistent with the record throughout the appeal period, not just as of March 2021. A 70 percent rating is warranted throughout the appeal period. In this regard, the Board has applied the "holistic analysis" in "assessing the severity, frequency, and duration of the signs and symptoms of the Veteran's service-connected mental disorder. Bankhead, 29 Vet. App. at 22. The Board has considered the objective medical evidence, including treatment records and examinations, and lay statements from the Veteran and his buddies. Further, the Board acknowledges the importance of suicidal ideation or thoughts in the rating criteria. Id. These were noted on occasion and explored in the record. In Bankhead, suicidal ideation was described as a continuum, at one end with passive suicidal ideation such as wishing you would not wake up and active suicidal ideation with plan on the other end, but that both were considered suicidal ideation in the 70 percent rating. The Court found in Bankhead that in some cases the finding of suicidal ideation may cause the level of social and occupational impairment described in the 70 percent rating. This supports our decision to grant 70 throughout the appeal period in this case. The next question for the Board is whether the Veteran's disability meets or more nearly approximates the criteria for a higher rating. Specifically, a 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name, warrants the maximum, 100 percent disability rating. The "such symptoms as" language means "for example," and does not represent an exhaustive list of symptoms that must be found before granting the rating of that category. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). The list of examples provides guidance as to the severity of symptoms contemplated for each rating. Id. However, this fact does not make the provided list of symptoms irrelevant. See Vasquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). The Veteran must still demonstrate either the particular symptoms associated with the rating sought, or other symptoms of similar severity, frequency, and duration. Id. at 117. The criteria for a rating in excess of 70 percent are not met or approximated at any time. The Veteran does not urge that he has the aforementioned level of symptoms. He has not endorsed total occupational and social impairment or relevant signs of the 100 percent rating criteria. Moreover, he is impaired in his occupational capacity but admittedly remains working in car dealerships. No evidence reflects that he meets or approximates the criteria for a 100 percent rating. Neither the examinations, nor the contemporaneous treatment records, show gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Rather, the examinations and treatment records reflect generally that these manifestations are not present. See, e.g., March 2021 PTSD exam findings. No examiner has found symptoms compatible with total occupational and social impairment. We note that no trained mental health examiner has found persistent danger of hurting himself. Thus, although the record overall reflects severe impairment, it does not remotely suggest find total impairment as required for a 100 percent rating. The criteria for a 100 percent rating under DC 9440 are not met or approximated. The Board has considered all psychiatric symptoms in reaching the above conclusions. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). In reaching such determination, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against a rating in excess of 70 percent. The benefit of the doubt doctrine is not applicable, and his claim must be denied as to a rating in excess of 70 percent. 38 C.F.R. §§ 4.3, 4.7. The degree of impairment has remained uniform at 70 percent throughout the appeal period. TDIU It is the established policy of VA that all Veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16. A finding of total disability is appropriate "when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation." 38 C.F.R. §§ 3.340 (a)(1), 4.15. "Substantially gainful employment" is that employment "which is ordinarily followed by the nondisabled to earn their livelihood with earnings common to the particular occupation in the community where the Veteran resides." Moore v. Derwinski, 1 Vet. App. 356, 358 (1991). Marginal employment shall not be considered substantially gainful employment. 38 C.F.R. § 4.16 (a). The Moore court cited the following language from Timmerman v. Weinberger, 510 F.2d 429 (8th Circuit 1975), in which United States Court of Appeals for the Eighth Circuit addressed unemployability in the Social Security disability context: The question must be looked at in a practical manner, and mere theoretical ability to engage in substantial gainful employment is not a sufficient basis to deny benefits. The test is whether a particular job is realistically within the physical and mental capabilities of the claimant. Moore, 1 Vet. App. at 359 (citing Timmerman at 442). In determining whether unemployability exists, consideration may be given to the Veteran's level of education, special training and previous work experience, but not to his age or to any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. The Veteran contends that his service-connected disabilities combine to render him unemployable. The preponderance of the evidence is against his theory, and the claim is denied. Importantly, the record does not reflect that the Veteran has submitted an updated complete VA Form 21-8940 (Veteran's Application for Increased Compensation Based on Unemployability), subsequent to the 2019 Board request which was communicated to the Veteran in a November 2020 development letter. That letter requested the Veteran fill out the attached form 8940 if he believed he qualified for the TDIU benefit. As discussed by the Board in 2019, while there was an older form from a 2012 claim, the RO denied the claim in an unappealed 2012 rating decision and updated information was needed. Nor has he returned any VA Form 21-4192 (Request for Employment Information in Connection with Claim for Disability Benefit), to be completed by each of the employers identified on VA Form 21-8940. The Board notes that the last page of the form 8940 was submitted but sections regarding employment and education history were not submitted. In any event, it appears from the evidence of record that throughout the period on appeal the Veteran has worked at automobile sales dealerships and demonstrated the ability to perform substantial gainful activity, and thus TDIU is not warranted. Initially, the Board notes that the Veteran meets the basic schedular rating criteria to be considered for TDIU set forth at 38 C.F.R. § 4.16 (a) inasmuch as his combined disabilities are rated 90 percent from January 1, 2010, even without factoring in the above grant of increased rating for PTSD throughout the appeal period and the grant of service connection for headaches herein. Specifically, his disabilities include PTSD, now rated 70 percent from August 24, 2011; obstructive sleep apnea rated 50 percent from January 21, 2010; lumbar spine disability, rated 40 percent from April 9, 2002; right and left lower extremity radiculopathy each rated 10 percent from October 29, 2009 and 20 percent thereafter; tinnitus, rated 10 percent and erectile dysfunction rated noncompensable from March 26, 2013. The migraine have not been rated at this time. The VA examination and treatment record is replete with reference to the fact that the Veteran has held jobs throughout the period on appeal, though he reportedly finds it stressful and has anger issues in addition to mood swings. It is also noted that he now has bad headaches. See February 2021 treatment note wherein he reported a desire to manage his PTSD symptoms, specifically his anger as he has noted it becoming problematic at work and home. He also repeatedly reported in his psychiatric treatment notes in 2020 and 2021 that he had spent between 12 and 20 out of the last 30 days working, in school or doing volunteer work. He reported in August 2020 that he was employed for 17 years in car sales and was currently employed. In a May 2020 treatment note he replied 'yes' he was currently working for pay. We do note five buddy statements submitted in March 2021 describing his anger outbursts and mood changes both at work and not at work. In June 2021 he reported that he had been in automobile sales since 2008. Here, we must note that all of the evidence points to the fact that the Veteran is still working, albeit with his service-connected disabilities. Consistent with this, March 2021 VA examinations which address the impact of his service-connected disabilities on occupational functioning also reflect that he remains able to work despite his disabilities. As he has chosen not to return a completed VA form 8940 as requested by the Board, he has declined to provide potentially clarifying information. We would be remiss if we did not note that he has indeed faxed multiple documents to VA since the remand was issued which reflect that they were sent from an automobile dealership fax machine. Here, it is not in dispute that the Veteran's service-connected disabilities are significant. Nonetheless, it remains equally uncontroverted that he continues to do work and work-like activities that show he is not precluded form substantial gainful activity. The overwhelming weight of the competent evidence demonstrates that he is not unemployable due to his service-connected disabilities. VA treatment record as discussed above reflects that the Veteran performs ongoing activities commensurate with employment. The Board cites to these activities to emphasize that not only is the Veteran working, he is clearly not precluded by any of his service-connected disabilities from performing physical and mental activities associated with securing and maintaining gainful employment. In sum, the Board finds that, throughout the relevant period, the Veteran was not unable to secure and follow a substantially gainful occupation as a result of his service-connected disabilities. The Veteran's assertions that he is precluded from working are outweighed by the repeated references to work and work-like activities in the treatment record. As such, the Board concludes that entitlement to a TDIU is not warranted and the Veteran's claim is therefore denied. 38 U.S.C. § 1155; 38 C.F.R. § 4.16. 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 claim, that doctrine is not applicable. Service Connection Veterans are entitled to compensation from VA if they develop a disability "resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty." 38 U.S.C. § 1110 (wartime service), 1131 (peacetime service). To establish a right to compensation for a present disability, a veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"-the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Certain chronic diseases will be presumed related to service if they manifested to a compensable degree within a presumptive period following separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2012); Fountain v. McDonald, 27 Vet. App. 258 (2015); 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a). Service connection may be granted for any disease initially diagnosed after service 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 is also warranted for a disability which is proximately due to, aggravated by or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310 (b). In evaluating a claim, the Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1335 (2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159 (a); Layno v. Brown, 6 Vet. App. 465, 470 (1994). Lay evidence can also be competent and sufficient evidence of a diagnosis if (1) the medical issue is within the competence of a layperson, (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. Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). If the evidence is competent, the Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this regard, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995). For a medical opinion (i.e., medical evidence) to be given weight, it must be: (1) based upon sufficient facts or data; (2) the product of reliable principles and methods; and (3) the result of principles and methods reliably applied to the facts. See Nieves-Rodriquez v. Peake, 22 Vet. App. 295, 302 (2008). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). Initially, the Board observes that while there is Gulf War service, there is no undiagnosed illness manifested by any of these alleged disorders none of the examinations of record have suggested that any of these disorders represents an undiagnosed illness. Indeed, in 2019, the Board ordered examinations to ascertain the etiology of these identified disorders. We also note that while there are extensive service treatment records, there is no separation examination. 1. Service connection for hypertension is denied. The Veteran claims entitlement to service connection for hypertension as directly related to his service and/or as secondary to his service-connected PTSD. See March 2013 VA Form 21-4138, Statement in Support of Claim. In December 2015, the Veteran underwent a VA examination, at which time, the examiner indicated that he had never been diagnosed with hypertension. In this regard, we note that service treatment records (STRs) are negative for any diagnosis or complaints of hypertension. Subsequently, his VA treatment records reflect that he was diagnosed with hypertension. See, e.g., May 2016 VA Primary Care Note. The question for the Board is thus whether the current disability manifested in service or within the applicable presumptive period or whether hypertension is otherwise related to service or is secondary to PTSD. We find that while there is current disability, there was no in-service incurrence or aggravation of a disease or injury nor is there a nexus between current disability and service nor is it due to or aggravated by PTSD. A March 2021 VA disability benefits questionnaire (DBQ) for hypertension was accomplished pursuant to 2019 BVA remand directives. The examiner confirmed the diagnosis of hypertension. The Veteran reported an onset date in 2016. After evaluation and review of the claims file, the examiner opined hypertension was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted STRs were negative for any diagnosis or complaints of hypertension, that he separated in 2000 and the diagnosis was in 2016, and no nexus was established. The examiner also opined that hypertension is less likely than not (less than 50 percent probability) proximately due to or the result of PTSD. The examiner noted that while research has shown that stress due to emotional and/or psychological issues (PTSD) can cause temporary elevations in blood pressure there is no scientific basis for the etiology of hypertension due to PTSD/stress. They also cited to medical literature and stated that hypertension is a vascular condition caused by the restriction of arterial and venous flow. Most patients with essential hypertension have a normal cardiac output but a raised peripheral resistance. Peripheral resistance is determined not by large arteries or the capillaries but by small arterioles, the walls of which contain smooth muscle cells. Contraction of smooth muscle cells is thought to be related to a rise in intracellular calcium concentration, which may explain the vasodilatory effect of drugs that block the calcium channels. Prolonged smooth muscle constriction is thought to induce structural changes with thickening of the arteriolar vessel walls possibly mediated by angiotensin, leading to an irreversible rise in peripheral resistance. Given the physiology of hypertension, no secondary relationship is established. The Board concludes that, while the Veteran has hypertension, which constitutes chronic disease under 38 U.S.C. § 1101(3); 38 C.F.R. § 3.309(a), it did not manifest in service or within a presumptive period, and continuity of symptomatology is not established. Rather, it was first shown years after service. 38 U.S.C. §§ 1101(3), 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a). The Veteran does not actually allege the condition was present in service, and there has been no continuity of symptomatology since service. Clearly, the diagnosis was in 2016 and the 2021 VA examiner confirmed this is the date of onset. The condition was not found during the 2015 VA exam. The Board accords substantial probative weight to the competent medical evidence, the treatment records (and the March 2021 VA medical opinion as to hypertension), which are the most probative evidence that the condition first manifested years after service, and not during service or during a presumptive period. The preponderance of the evidence is also against finding that a nexus exists between the Veteran's hypertension and service. 38 U.S.C. § 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). Here, the Board notes that the condition has not been related to service by any competent evidence. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. None of the treatment records contains an opinion that hypertension or is related to service. The negative opinion of the March 2021 VA examiner contains a rationale that was sound and fully considered the evidence of record. It noted that STRs did not contain complaints, treatment, or diagnosis for hypertension and that the condition was not shown until 2016, 16 years after he was released from active duty. Hypertension was not noted, diagnosed or manifest in service or within one year of separation. Any assertion of continuity is accorded less probative value than the lack of complaints or findings for years following service. While the Veteran believes hypertension is related to service, his lay opinion as to a nexus is outweighed by negative treatment record and the well-supported opinion of the VA examiner in 2021 as to hypertension. There is no competent/credible evidence that hypertension is related to service. The weight of the evidence is against concluding that any such disease was incurred in service or is otherwise related to service. 38 C.F.R. § 3.303 (d). We find the 2021 opinion of the VA examiner, made based upon a thorough review of the claims folder, well-supported with references to the record and medical literature. The opinion is more probative as to the issue of whether current disability is related to service than the Veteran's lay assertions. His assertions pale in comparison to the opinion of a trained medical professional. The VA examiner considered the Veteran's theory as to relationship and provided sound reasons for ultimately rejecting it. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). The 2021 opinion is the most probative evidence. We accord it significant probative weight. There is no competent evidence that hypertension is related to service. The Veteran's lay opinion is wholly unsupported. As to the contention that hypertension was alternatively proximately due to or aggravated by service-connected disability, the examiner opined in the negative as well. We also find the 2021 opinion of the VA examiner to be the most probative evidence as to the issue of whether current disability is proximately due or aggravated by service-connected PTSD. The Veteran's assertions again pale in comparison to the opinion of a trained medical professional. The VA examiner considered the Veteran's theory as to relationship and provided sound reasons for ultimately rejecting it. There is no competent evidence that hypertension is proximately due to or aggravated by service-connected disability. Thus, the Veteran's lay opinion as to secondary service connection is wholly unsupported. The preponderance of the evidence is against the claim. The benefit sought on appeal is denied. 2. Entitlement to service connection for a cervical spine disorder is denied. 3. Entitlement to service connection for a left upper extremity disorder, to include any musculoskeletal disorder associated with the left shoulder and/or neurological disorders is denied. 4. Entitlement to service connection for a right upper extremity disorder, to include any musculoskeletal disorder associated with the right shoulder and/or neurological disorders is denied. 5. Entitlement to service connection for a left knee disorder is denied. 6. Entitlement to service connection for a right knee disorder is denied The Veteran claims entitlement to service connection for a cervical spine disorder and his upper extremities to include shoulders, as well as his knee problems. Specifically, he claims that he injured his cervical spine and upper extremities and knees after falling from a tank in 1991 in Saudi Arabia, and that he has experienced chronic neck pain since that time. Alternately, he urges the upper extremity disorder is due to his neck which should be service-connected. See, e.g., August 2010 VA Form 21-4138, Statement in Support of Claim; April 2013 Notice of Disagreement; March 2021 VA knees examination. The question for the Board is whether the Veteran has current disability that manifested in service or within the applicable presumptive period or whether any such disability is otherwise related to service. We find that while there is current disability as to the knees, cervical spine and upper extremities, there was no in-service incurrence or aggravation of a disease or injury nor is there a nexus between current disability and service; no arthritis was manifest within the presumptive period. A May 1991 STR notes the Veteran's history of intermittent neck pain after a fall from a tank. An August 1991 record notes the Veteran's complaint of bilateral shoulder pain after he fell off a tank in Saudi Arabia. A June 1997 service treatment record noted the Veteran's 1991 fall, as well as his report of right-sided neck pain. He was assessed with right neck spasm. As to the knees, a June 1986 STR noted his report of right knee pain for three weeks. The Veteran denied any trauma. September 1990 and October 1990 records noted the report of left knee pain when running. In October 1990, he was diagnosed with retropatellar pain syndrome. In July 2000, he was seen for swelling of the left knee and pain. A December 2009 VA treatment record noted the Veteran's report of early morning tingling in his left arm and hand. EMG testing revealed early sensory peripheral neuropathy in the upper extremities. A May 2010 statement from his private treatment provider notes his fall from a tank in 1991, as well as his in-service complaints of neck pain and right shoulder pain with mid and sacral back pain. She also noted the Veteran's complaint of right shoulder pain radiating from his neck, and that his pain began in 1991 after his fall from a tank. Unfortunately, she did not provide any rationale in support of her opinion. In August 2010, the Veteran underwent a VA examination. The Veteran reported his in-service fall from a tank, and he stated that he injured his cervical spine and had right shoulder pain. Ultimately, he was diagnosed with cervical degenerative joint disease; however, no opinion was offered as to whether the Veteran's current cervical spine disorder was related to his military service. VA examination in September 2011 reflects diagnosis of bilateral knee pain without pathology and less likely than not caused by or the result of his military service. The examiner reasoned that, despite his in-service complaints of bilateral knee pain there was no history of trauma to either knee, he had been out of service for ten to eleven years, he did not seek post-service treatment for his knees, and there was no evidence of record demonstrating that his current bilateral knee disorders were related to his military service. In August 2012, the Veteran underwent a VA Gulf War examination, at which time he reported pain from the right shoulder up into the right side of his neck. There was a loss of motion in the shoulder and the neck during flare-ups, as well as a loss of function. The examiner noted that he had been diagnosed with degenerative disc disease of the cervical spine; therefore, there was no "undiagnosed illness" related to his neck complaints. No opinion was offered as to whether the Veteran's current cervical spine disorder was related to his military service. There was no diagnosis for the Veteran's bilateral knee pain but it was noted there was no MRI. An August 2012 VA knee examination noted that the Veteran had never been diagnosed with any knee-related disorder. The Veteran reported pain in both knees when he walked up steps. In February 2016, the Veteran underwent another VA examination. The examiner noted his diagnosis of degenerative disc disease of the cervical spine and mild stable degenerative changes of both acromioclavicular joints. She stated that the diagnoses had a clear and specific etiology; and were not undiagnosed illness, a diagnosable but medically unexplained chronic multisymptom illness of an unknow etiology, or a diagnosable but medically unexplained chronic multisymptom illness with a partially explained etiology. She stated that his cervical spine and shoulder disorders were less likely related to any in-service environmental exposure during the Veteran's service in Southwest Asia because there was no specific exposure event during service. The examiner stated that the Veteran's current problems were consistent with age-related changes. She then included summaries of medical articles discussing degenerative disc disease and spondylolisthesis. The Board in 2019 ordered remand for examinations of cervical spine and upper extremities as well as the knees, noting the record was insufficient to adjudicate the claim. Also, as to the knees, it was noted that pain alone, even in the absence of a diagnosis or underlying pathology, can establish a current disability under 38U.S.C. §§1110 if it results in functional impairment of earning capacity. Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). VA DBQ of the shoulders in October 2020 reflects left side status post subacromial decompression, distal clavicle excision and biceps tenodesis in 2020, less likely than not (less than 50 percent probability) incurred in or caused by service. The examiner noted that during service, left bicep condition, was acute only. While the Veteran notes injury to the bilateral shoulder s/p fall from tank in 1991 and ongoing symptoms, there is no separation exam or report of medical history at separation available for review. The claims folder reveals a normal shoulder X-ray in 2012 and in 2016 the Veteran had mild arthritis which is related to age and wear/tear. There is no evidence of a bicep tendon tear in service. The finding of shoulder bicep tendonosis with decompression in 2020 is noted and while the Veteran notes symptoms ongoing since service, this does not equate to diagnosis. There is no evidence of chronicity of care of the acute symptoms s/p fall in 1991. A nexus has not been established per the examiner. There was a normal evaluation for the right shoulder. Parenthetically, we note that in a November 2020 rating decision, service connection for left shoulder, status post subacromial decompression, distal clavicle excision and biceps tenodesis (claimed as bicep tendon tear) was denied. The instant claim as to the left upper extremity remained on appeal as reflected in the 2021 supplemental statement of the case. March 2021 VA DBQs reflect negative etiological opinions. Bilateral cervical spine stenosis from 2013 and degenerative arthritis and stenosis of the cervical spine from 2010 were noted and the Veteran reported onset of the condition as 1991 after a fall. After a review of the file, the examiner reported the cervical spine condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted that while the Veteran noted cervical spine symptoms began in 1991 after falling from a tank during active duty, medical examination from 1992 noted normal spine and was silent for any cervical spine symptoms. The examiner concluded that if the condition existed during active duty in the 1990's, findings would be more significant than mild disease. In addition to noting bilateral cervical spinal stenosis, the March 2021 VA examination also reflect reported radicular pain that is electric like and radiates into the arms or hands. Examination revealed radiculopathy affecting the upper radicular group. The examiner stated radiculopathy is secondary to the cervical spine disability. As to the knees, the March 2021 VA examination with X-ray reflects left knee arthritis and patellar tendonitis and right knee patellofemoral pain syndrome and osteoarthritis. The knee conditions were less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. As to the left knee, the examiner noted he was seen twice in service in 1990 and once in 2000 for left knee pain only. The examiner noted he had been out of the service over 20 years and had not been seen for a knee condition. As to the right knee, there was no history of trauma and he had been out of the service over 20 years and had not been seen for a knee condition. Additional VA medical evaluations for the knees and cervical spine dated in June 2021 merely reflect, in pertinent part, that the Veteran arthritis of the right and left knee and cervical spine. There is current disability of cervical spine, upper extremities and knees. Here, the STRs reflect some complaints in service, but these were considered by the VA examiners in 2020 and 2021 to not be related to the current conditions. The Board concludes that, while the Veteran has arthritis of the cervical spine, left shoulder and knees, which constitutes chronic disease under 38 U.S.C. § 1101(3); 38 C.F.R. § 3.309(a), as well as radiculopathy in the upper extremities which could be considered to represent other organic diseases of the nervous system, these did not manifest in service or within a presumptive period, and continuity of symptomatology is not established. Rather, they were first shown years after service. 38 U.S.C. §§ 1101(3), 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a). To the extent that the Veteran alleges the conditions were present in service, and there has been continuity of symptomatology since service, the medical record is against his assertions. His assertions are outweighed by the negative treatment record for years following service in conjunction with the aforementioned 2020 and 2021 VA examiner's opinions. While the Veteran is competent to report having experienced certain symptoms, his assertions are considered not credible to the extent that he urges he had symptoms since service or during service or within the presumptive period due to (1) the minimal reports in service and in the years following service with (2) the gap in time between service and the first documentation of signs and symptoms of the current conditions years later. The Board accords substantial probative weight to the competent medical evidence, the treatment records (and the March 2021 VA medical opinions), which are the most probative evidence that these conditions first manifested years after service, and not during service or during a presumptive period. The Veteran's assertions are outweighed by this evidence. The preponderance of the evidence is also against finding that a nexus exists between the Veteran's cervical spine, upper extremity or knee disorders and service. 38 U.S.C. § 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). Here, the Board notes that these conditions have not been related to service by any competent evidence. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. The opinions of the October 2020 and March 2021 VA examiners are wholly against the claims. These VA examiners considered the Veteran's theory as to relationships and provided sound reasons for ultimately rejecting it. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). They acknowledged his tank fall. The 2020 and 2021 opinions are the most probative evidence. We accord them significant probative weight. There is no competent evidence that cervical spine disability, bilateral upper extremity disability or bilateral knee disability is related to service. The Veteran's lay opinion is wholly unsupported. The weight of the evidence is against concluding that any such disease was incurred in service. 38 C.F.R. § 3.303 (d). As to the contention that a bilateral upper extremity disability was alternatively proximately due to or aggravated by service-connected disability, we note that as service connection for cervical spine disability is being denied, secondary service connection based on that disability is not for consideration. The preponderance of the evidence is against the claims; the appeal is denied. 7. Entitlement to service connection for a headache disorder is granted. The Veteran claims entitlement to service connection for a headache disorder. Specifically, he claims that he started to experience chronic headaches during service, and that they have continued to the present. See, e.g., December 2009 VA Form 21-4138, Statement in Support of Claim. The Veteran attributes his headaches to the 1991 injury when he fell off the tank he contends that he hit his head and that he has experienced headaches ever since. See September 2012 VA VA Polytrauma Consult. The Veteran also claims that his headaches are to due environmental exposures as a result of his service in the Persian Gulf or in-service hazardous noise exposure. See April 2013 Notice of Disagreement. Alternatively, the Veteran argues that his headaches disorder is secondary to his service-connected lumbar spine disability. See, e.g., July 2010 VA Form21-4138, Statement in Support of Claim. The question for the Board is whether the Veteran has current headache disability that manifested in service or within the applicable presumptive period or whether any such disability is otherwise related to service. We find that there is current disability that has been present since service. An October 1985 service treatment record noted the Veteran's report of headaches after using a simulator. October 1986 and March 1987 service treatment records reflect his complaint of a cold along with headaches. In November 1993, he reported sinus headaches. An April 1998 service treatment record reflects the Veteran's report of daily headaches which he believed was due to his right-sided sinus problems. During a December 2002 VA examination, the Veteran reported chronic migraines that began in 1991, and that he experienced daily headaches since that time. In December 2009 statements, the Veteran's wife and two friends stated that the Veteran had complained of headaches for as long as they have known him. A January 2010 VA treatment record noted a diagnosis of a headache disorder. A May 2010 statement from his private treatment provider reports that the Veteran had experienced daily headaches since April 1998, and she expressed concern that his headaches may be associated with his chronic neck pain, and she also stated that the Veteran's pain began in 1991 after his fall from a tank, but there was no rationale in support of her conclusion. In June 2010, he submitted a statement from his ex-wife who noted that she was married to the Veteran from June 1991 to the end of 1996. She recalled that, throughout this time, he would experience chronic migraines and headaches. An August 2010 VA examination attributes headaches to the cervical spine disorder. VA examination in December 2015 reflects there was no proper work up and no diagnosis of headaches. VA examination in February 2016 reflects this same finding and noted today's neuropsychiatric evaluation was negative for causation of his complaints of "headaches." They found there was no undiagnosed illness, diagnosable but medically unexplained chronic multisymptom illness of an unknow etiology, diagnosable but medically unexplained chronic multisymptom illness with a partially explained etiology or a diagnosis with a clear and specific etiology. They also stated that his headaches were less likely related to any in-service environmental exposure during the Veteran's service in Southwest Asia. In 2019, the Board remanded because it found that a new examination was warranted to ensure an adequate record. The March 2021 VA examination included a diagnosis of migraine including migraine variants. The Veteran reported right-sided headaches causing problems with the right eye and light sensitivity. The examiner found the headache disorder was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that while the Veteran notes headaches began in 1990/1991, medical examination from 1992 noted normal neurological system. The examiner also pointed out in a report of medical history from 1994, he marked no to frequent or severe headaches. The examiner also found the headache disorder is less likely than not (less than 50 percent probability) proximately due to or the result of Veteran's service-connected condition. The examiner reported headaches are a separate entity entirely from the degenerative disc disease of the lumbar spine and unrelated to it. A large list of possible causes of secondary headaches was provided as cited from medical literature, and it was concluded that a nexus was not established. We note parenthetically that one of the items listed was panic attacks and his PTSD is characterized by panic attacks. Critically, there are current migraine headaches. The Veteran has reported ongoing headaches since service, wherein he did make complaints of headaches. Lay statements from other people in his life also reflect this fact. Headaches themselves are largely subjective and the Veteran and other lay people are competent to report on them as they are capable of lay observation. The lay statements are basically consistent and not inherently incredible. We conclude that the evidence is in relative equipoise as to whether migraines are related to service. In sum, while acknowledging the negative 2021 VA medical opinion, the Board does not find any evidence sufficient to overcome the aforementioned evidence that the current migraine headaches were incurred in service. Service connection is granted. H. N. SCHWARTZ Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Rippel, 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.