Citation Nr: 21073172 Decision Date: 12/07/21 Archive Date: 12/07/21 DOCKET NO. 17-27 629 DATE: December 7, 2021 ORDER Entitlement to service connection for a low back condition is denied. Entitlement to service connection for hypertension is denied. Entitlement to service connection for depression is granted. FINDINGS OF FACT 1. The preponderance of the evidence is against finding the Veteran's low back condition is related to service. 2. The preponderance of the evidence is against finding the Veteran's hypertension is due to his service, to include his increased sodium intake. 3. Resolving all reasonable doubt in the Veteran's favor, his depression is related to service. CONCLUSIONS OF LAW 1. The criteria for service connection for a low back condition have not been met. 38 U.S.C. §§ 1110, 1111, 6103, 5103A, 5017; 38 C.F.R. §§ 4.102, 3.303, 3.304. 2. The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1110, 1111, 6103, 5103A, 5017; 38 C.F.R. §§ 4.102, 3.303, 3.304. 3. The criteria for service connection for depression are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the United States Army from November 1978 to February 1982. These matters come before the Board of Veterans' Appeals (Board) on appeal of an April 2013 rating decision denying the reopening of claims for service connection for a low back condition and hypertension, as well as an original claim for service connection for PTSD. These matters were previously before the Board in June 2021, during which time the Board found new and material evidence and reopened the claims for service connection for a low back condition and hypertension. The Board proceeded to remand the service connection claims for a low back condition, hypertension, and PTSD in order to obtain VA examinations per McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Veteran testified before the undersigned Veterans Law Judge at a videoconference hearing in March 2021, and a transcript of this hearing has been associated with the claims file. These matters now return to the Board for further appellate review. Service Connection Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110. Generally, the evidence 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. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). 1. Entitlement to service connection for a low back condition is denied. The Veteran contends his low back condition is due to service, including a back injury during his airborne training. The Veteran was afforded a VA examination in September 2021, in which the examiner diagnosed the Veteran with a lumbosacral strain. The Veteran reported that during ranger training, he went up to the top of a tower and when he was released, he was yanked down and felt his back clamp. He was prescribed medication and a heating pad for a week but was unable to complete his ranger training after this injury. The Veteran further reported he continued to have pain in his lower back. The examiner ordered x-rays during the examination and noted they were negative for arthritis. Additionally, the examiner noted the earliest reference to lower back pain in the Veteran's treatment records was in 2009, at which time the x-ray taken noted no fracture, spondylosis or listhesis, nor other acute changes. The examiner opined that the Veteran's low back condition was less likely than not due to service because the Veteran was not shown to have a low back disability during service or within a year of service. Regarding the Veteran's bilateral trapezius muscle injury in March 1979, the examiner stated that these muscles are in the upper body and are unrelated to the Veteran's lower back pain. The examiner therefore opined the Veteran's low back condition was less likely than not related to his service. In the March 2021 hearing, the Veteran testified that he became light-headed and blacked out during his airborne training, which caused him to fall down, and he could not move. Additionally, he explained that he has had back pain since this in-service fall. The Veteran's service treatment records (STRs) note that he was seen for possible sickle cell disease in February 1979 (a known symptom of which is fainting), and he suffered a bilateral trapezius muscle injury in March 1979. The Veteran did not undergo a separation examination because after reviewing his service records in February 1982, the reviewing physician found one was not necessary. His January 1988 Army Reserves enlistment examination and November 1992 Report of Medical History note no back pain or prior back injury. The Veteran did, however, report that he sustained a back injury during his Advanced Individual Training in 1979 on a January 1997 Annual Medical Certificate. The Veteran has a current diagnosis of a lumbosacral strain, and thus the first element of service connection has been met. Additionally, the Veteran reported injuring his back during AIT, and his STRs indicate he suffered a bilateral trapezius muscle injury during service. As such, the second element of service connection has been met. The remaining question is whether there is a nexus between the Veteran's low back condition and his service injury. After reviewing the record, the Board finds the preponderance of the evidence is against finding the Veteran's low back condition is due to service. Although the Veteran has stated he experienced continuous back pain from his injury in March 1979 until present, the Veteran's STRs, as well as his VA and private treatment records, do not support this. To the contrary, the Veteran indicated on his January 1988 and November 1992 Army Reserve entrance examinations that he did not experience any back pain. Additionally, while the Veteran did note he injured his back during AIT in 1979 on a January 1997 Annual Medical Certificate, this is not sufficient enough evidence that the Veteran's current low back condition is due to his service. Additionally, the examiner noted the first indication of a low back condition in the Veteran's treatment records was in 2009, approximately 30 years after the reported injury event. Furthermore, while the Veteran is competent and credible to report on the symptoms he experiences, he lacks the training to opine whether his low back condition was related to his service. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Accordingly, the Board finds that the evidence is against finding the Veteran's low back condition is not due to or otherwise related to his service. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply, and the claim is denied. See Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001) 2. Entitlement to service connection for hypertension is denied. The Veteran contends that his hypertension is due to his service, to include eating high-sodium foods while in service. The Veteran underwent a VA examination in September 2021, during which the examiner noted the Veteran was diagnosed with hypertension in 2001. The Veteran reported he was first diagnosed with hypertension in 1981 or 1982, after he was evaluated for complaints of dizziness and heart ache, at which time his blood pressure was noted as being elevated, and he was placed on medication. The examiner stated that they could not locate the February 1999 medical review noting that the Veteran had slight hypertension that was well controlled with medication, but instead stated the earliest mention of hypertension found in the record was from 2001. The examiner opined that while the Veteran reported an increased sodium intake during service, there were no findings related to hypertension upon separation from service in 1982. As such, the examiner found it less likely than not that the Veteran's hypertension was due to his service. During the March 2021 hearing, the Veteran testified that he did not have hypertension prior to service, and he also stated he ate a lot of high sodium foods during service. He believes that his high-sodium diet during service caused his current hypertension, which he said was diagnosed within one year of separating from service. The Veteran's STRs include a January 1988 and November 1992 Army Reserves entrance examination, neither of which note a diagnosis of hypertension. Additionally, an Initial Medical Review Annual Medical Certificate dated February 1999 shows that the Veteran reported "slight hypertension, on controlled pass 7 months, doctor said perfect health." The form further indicates the Veteran was diagnosed with slight hypertension approximately one year prior, and the reviewing physician found his hypertension to be well controlled with medication. The Veteran has a current diagnosis of hypertension, and thus the first element of service connection has been met. Additionally, high sodium intake is associated with hypertension, and therefore the Veteran's report of high sodium intake during service satisfies the second element of service connection. The remaining question is whether a nexus exists between the Veteran's hypertension and his service. After reviewing the evidence of record, the Board finds the preponderance of the evidence is against finding that his hypertension is due to or otherwise related to his service. Although the Veteran testified that he was first diagnosed with hypertension and placed on medication in 1981 or 1982, his January 1988 and November 1992 Army Reserve entrance examinations both indicate the Veteran did not have hypertension. Additionally, the Veteran indicated in a February 1999 Annual Medical Certificate that he had been diagnosed with slight hypertension within the previous year, approximately 15 years after his separation from service. Furthermore, while the Veteran is competent and capable to report symptoms experienced, his in-service eating habits, and what previous physicians have told him, he lacks the training to opine whether his current hypertension is related to his service. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). The September 2021 VA examiner's opinion is clear and well-explained, and there is no competent and probative evidence to the contrary. For the reasons above, the Board finds that the evidence is against finding the Veteran's hypertension is due to or otherwise related to his service. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply, and the claim is denied. See Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). 3. Entitlement to service connection for depression is granted. The Veteran contends that his acquired psychiatric disorder is due to his service, to include as related to a back injury he suffered during his airborne training. The Board concludes that the Veteran has a current disability that is related to his time in service. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Here, the Veteran has a diagnosis of major depressive disorder. See VA Examination, September 2021. As discussed above, the Board concedes that he experienced an in-service injury to his back during AIT. Thus, the question becomes whether the current disability is related to service. The Veteran was afforded a VA examination in September 2021, during which he was diagnosed with major depressive disorder. During the examination, the Veteran reported that his back injury during AIT derailed his airborne training, which made his depression symptoms worse because he felt he was forced to compromise his career because he could no longer do what he set out to do when he joined the military. The examiner ultimately opined the Veteran's depression was less likely than not directly due to his military service because he reported experiencing depression well before entry into service. However, the examiner did opine that the Veteran's depression was at least as likely as not exacerbated by his reported back injury during service. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran's current major depressive disorder is related to service. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for major depressive disorder is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Caroline B. Fleming Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Gabrielle Ongies, 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.