Citation Nr: 21073690 Decision Date: 12/10/21 Archive Date: 12/10/21 DOCKET NO. 16-62 822 DATE: December 10, 2021 ORDER Entitlement to service connection for hypertension is denied. Entitlement to service connection for a lumbar spine disorder is granted. Entitlement to service connection for a left knee disorder is granted. FINDINGS OF FACT 1. Hypertension is not shown to be causally or etiologically related to any disease, injury, or incident during service and did not manifest to a compensable degree within one year of separation of service. 2. Resolving all doubt in the Veteran's favor, a current lumbar spine disorder, diagnosed as low back strain and degenerative arthritis of the spine, is related to his military service. 3. Resolving all doubt in the Veteran's favor, a current left knee disorder, diagnosed as degenerative arthritis of the spine, post-arthroplasty, is related to his military service. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for service connection for a lumbar spine disorder are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for a left knee disorder are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1970 to July 1974 and from March 1975 to March 1991. These matters come before the Board of Veterans' Appeals (the Board) on appeal from September 2012 and January 2013 rating decisions. In August 2019, the Board remanded the Veteran's claim of entitlement to service connection for hypertension, a lumbar spine disability, and a left knee disability for additional development; they now return for further appellate review. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, 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). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996). Where a veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, such as cardiovascular diseases, to include hypertension, and arthritis, to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one-year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309 (a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Entitlement to service connection for hypertension. The Veteran seeks service connection for hypertension, which he contends had its initial onset during military service. Review of the Veteran's service treatment records (STRs) show several blood pressure readings from 1974 to 1989. Significantly, on three consecutive days in late August and early September 1987, the Veteran had blood pressure readings of 144/80, 134/76, and 160/90. Also, on January 23, 1979 and August 8, 1978, the Veteran's single blood pressure readings were 136/90 and 140/100, respectively. Thereafter, in October 1988, the Veteran reported a history of high blood pressure on a Report of Medical History. However, a methodical review of the Veteran's STRs fails to reflect any other elevated blood pressure readings. Rather, all other recorded systolic pressure readings ranged from 122 to 145, and the recorded diastolic pressure readings ranged from 70 to 88, all of which fall short of readings deemed indicative of hypertension, as that term is defined for VA purposes. See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1) (defining elevated blood pressure as systolic readings of 160mm or greater or diastolic pressure readings of 90mm or greater). The Veteran has been afforded multiple VA examinations to evaluate his claim of hypertension related to service, to include the isolated readings of 160/90, 136/90, and 140/100. In this regard, a January 2012 VA examiner opined that his hypertension is not caused by or related to military service, only stating that this opinion is "based on medical evidence." However, as the examiner did not support his opinion with a sufficient rationale, another opinion was obtained in December 2016. At such time, the VA examiner took note of the elevated blood pressure readings during service, however, he stated that the readings were either related to an acute illness or resolved as later blood pressure readings demonstrated later on. As such, the examiner determined that the Veteran did not meet the diagnostic criteria for hypertension while on active duty. For these reasons, the examiner concluded that the Veteran's current hypertension is less likely than not related to the elevated blood pressure readings during service. However, this opinion was based on an inaccurate factual premisenamely, that the Veteran's three separate elevated blood pressure readings were associated with acute illness. Accordingly, final addendum opinions were obtained in December 2019 and July 2020. These VA examiners once again reviewed the evidence of record, to include the Veteran's STRs, and concluded that the objective medical evidence of record still does not support a finding that the Veteran met the diagnostic criteria for hypertension during his military service or in the year after separation from service, or that his current hypertension is otherwise related to his military service. The Board finds especially probative the December 2019 VA opinion, which lists the in-service blood pressure readings and explains that such do not meet the diagnostic requirements for hypertension for VA purposes. In this regard, no isolated elevated reading was followed by elevated follow-up readings and the Veteran was not diagnosed with or treated for hypertension during service. Furthermore, the examiner noted that no elevated readings were recorded in 1990 or 1991, proximate to separation from service, to include a March 1991 blood pressure reading of 114/78 which registered well under the diagnostic range for hypertension. To support this opinion, the July 2020 examiner also emphasized that there was no medical evidence to support a diagnosis of hypertension with onset during or in the year following separation from service. The Board acknowledges a private opinion submitted by the Veteran in November 2010 stating that his current hypertension could possibly be related to his military service. However, such opinion was not supported by any rationale, and the examiner failed to state that it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's current hypertension is related to his military service. Furthermore, while the private treatment provider acknowledged the three isolated elevated readings during service, he did not conclude that such readings were diagnostic of hypertension at that time. Without an adequate rationale for the nexus opinion provided, the Board cannot afford this opinion probative weight. Rather, the Board affords great probative weight to the December 2019 and July 2020 VA examiners' opinions, as both collectively considered all of the pertinent evidence of record, to include the statements of the Veteran and the Veteran's relevant medical history, and provided a complete rationale, relying on and citing to the records reviewed. Moreover, the examiner offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). While the Board acknowledges the Veteran's recollection of having elevated blood pressure during service, the Board affords more probative weight to the blood pressure readings recorded in his contemporaneous STRs and the findings of his medical providers, who have concluded that such readings were not diagnostic of hypertension until at least 2001a full decade after separation from service. Cucuras v. Sec'y of Health and Human Servs., 993 F.2d 1525, 1528 (Fed. Cir. 1993) (finding no error in fact-finder's decision to give more weight contemporaneous medical records generated for treatment purposes than to contrary lay testimony, reasoning that "[m]edical records, in general, warrant consideration as trustworthy evidence, and that "oral testimony in conflict with contemporaneous documentary evidence deserves little weight"). Further, the Veteran's blood pressure was recorded as 114/78 during the VA medical examination conducted in March 1991 (which was performed proximate to his discharge from service), thereby failing to suggest that the Veteran developed hypertension to a compensable degree within the year after service. See id. (setting forth the criteria for a compensable rating for hypertension, namely diastolic pressure predominantly 100 or more, or a history thereof, or systolic pressure predominantly160 or more). Rather, the first diagnosis of hypertension of record is noted to be in 2001 or later, many years after service, and there is no competent opinion linking such disorder to the Veteran's military service. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007) (holding that a lay person is not considered competent to testify regarding medically complex issues); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (explaining that while the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Finally, the Veteran noted at the time of separation from service that, other than knee pain, he was in good health. In sum, the more probative evidence of record reflects that the Veteran did not have elevated blood pressure sufficient to support a diagnosis of hypertension for VA purposes during service, or within the year following his discharge from service. Therefore, the Board finds that service connection for hypertension is not warranted. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim for service connection for hypertension. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49. 2. Entitlement to service connection for a lumbar spine disorder. The Veteran seeks service connection for a lumbar spine disability, diagnosed as low back strain and degenerative disc and joint disease. The Veteran contends that his current lumbar spine disability is related to injuries he suffered to his lower back during service. Turning to the evidence of record, review of the Veteran's STRs shows that the Veteran sought medical treatment for lower back pain and injuries on multiple occasions from June 1976 to June 1990. He was diagnosed with chronic lower back pain and lumbar muscle strain. Specifically, the Veteran was diagnosed with a lumbar spine strain on September 24, 1976 after moving furniture, though he also sought treatment for low back pain as early as June 1976. The Veteran was thereafter diagnosed with lumbar strain following an injury playing basketball on March 1, 1985. Prior to separation from service in 1991, the Veteran again sought treatment in June 1990 for chronic low back pain with muscle tenderness and spasms, which he reported had been ongoing for the past year. He reported re-injury in the location of the chronic pain, stating that he experienced additional pain when transporting light-weight objects from a car into a building. The Board notes that the Veteran did not specifically report back pain on his March 5, 1991 retirement physical; however, he did report "swollen or painful joints" and "arthritis, rheumatism, or bursitis." As noted in the August 2019 Board remand, the Veteran underwent a VA examination in January 2012. The VA examiner found the Veteran to have a significant degenerative condition of his lumbar spine, however, the examiner opined that there is no evidence to suggest this condition is due to service. However, such opinion was conclusory and not supported by sufficient medical rationale. Accordingly, VA obtained an addendum medical opinion in December 2016. The VA examiner noted only three instances of lumbar spine complaints in the Veteran's STRs. He opined that the Veteran's injuries during service are considered "minor traumas," which would not result in degenerative disease years later. Moreover, the examiner also stated that the STRs do not demonstrate a persistent back condition during active duty. Instead, the examiner opined that the Veteran's in-service injuries were "minor, self-limiting conditions which resolved." However, this finding is refuted by a June 1990 medical record in which the Veteran reported experiencing chronic low back pain for at least one year. Moreover, the record indicates that the Veteran has reported experiencing continuous back pain ever since service. As the December 2016 VA examiner based his opinion on an incomplete review of the Veteran's STRs and did not consider the Veteran's competent reports regarding the in-service onset of low back pain and his continuous symptoms since, the Board found this opinion to be inadequate and remanded the claim for a new opinion in August 2019. While a new opinion was obtained in July 2020, the Board finds that this opinion also contains an insufficient rationale for the negative nexus opinion provided. In this regard, the examiner simply stated that no STR shows diagnosis of or treatment for a degenerative lumbar spine condition. Nonetheless, the sole basis for a negative opinion cannot be based on the lack of medical documentation demonstrating an in-service diagnosis of degeneration, especially in light of the fact that the Veteran was treated multiple times during service for lower back pain, to include after injuries while moving furniture and playing sports. Therefore, the Board again finds this opinion to be inadequate. Conversely, the Veteran submitted a medical opinion from his private physician in July 2013, who opined that the Veteran's lumbar spine disability is most likely directly related to the chronic back injuries suffered during military service. In this regard, the Veteran's private treatment provider noted that the Veteran complained of lumbar back pain dating back to his time in service. The doctor noted a review of the Veteran's medical records, to include STRs, and opined that the Veteran's currently diagnosed severe central canal stenosis and disc bulging, with osteophyte formation, is most likely the direct result of his in-service low back injuries and back pain, documented as early as June 30, 1976. The Board notes that this opinion was deemed inadequate in the August 2019 Board remand; however, upon further review of the record, the Board finds that, when considered with the credible lay statements of the Veteran and supporting STRs, such opinion is sufficient to support a grant of service connection for a lumbar spine disorder in the instant case. In this regard, the Board finds the July 2013 private treatment provider's opinion to be highly probative as it considered all of the pertinent evidence of record, to include the statements of the Veteran, and provided a complete rationale, relying on and citing to the records reviewed. Moreover, the examiner offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves, at 295; Stefl, at 124. Furthermore, this probative opinion is consistent with the Veteran's competent reports that he has experienced the same low back symptomatology since injuring his low back multiple times during service. Therefore, in light of the Veteran's in-service treatment and diagnosis of low back pain and strain, his current diagnosis of lumbosacral strain with degenerative joint disease, and the favorable July 2013 opinion, the Board resolves all doubt in favor of the Veteran and finds that his currently diagnosed lumbosacral strain with degenerative joint disease is at least as likely as not related to his military service. Consequently, service connection for the lumbar spine disorder is warranted. 3. Entitlement to service connection for a left knee disorder, to include as secondary to a service-connected right knee disability. The Veteran seeks service connection for a left knee disorder, which he contends was incurred in or related to military service. In the August 2019 remand, the Board recharacterized the issue to reflect evidence of record indicative of a secondary claim for service connection for a left knee disorder due to a service-connected right knee disability. As an initial matter, the Board notes that the Veteran has a current diagnosis of degenerative joint disease of the left knee, and he underwent a total left knee arthroplasty in April 2009. See December 2019 VA Compensation and Pension Report. As noted in the August 2019 remand, the Veteran's STRs reflect ongoing treatment for left knee pain during military service. Furthermore, he was diagnosed with patellofemoral syndrome of the left knee during service. In this regard, an April 5, 1978 STR documents left knee edema and pain, with some crepitus; a January 23, 1979 STR shows pain in the left knee with tenderness and difficulty walking after playing basketball; a February 23, 1979 STR documents complaints of pain and swelling in the left knee since the right knee medial meniscectomy one year prior; an August 8, 1990 STR documents complaints of pain with recurrent swelling and stiffness in the left knee, with a first impression of degenerative joint disease rather than patellofemoral syndrome despite a normal examination; an October 19, 1990 STR reflects a diagnosis of left knee patellofemoral syndrome; and a March 5, 1991 separation examination report records ongoing complaints of left knee pain. In order to determine whether the Veteran's current left knee disorder is related to in-service left knee issues and diagnosis, the Veteran underwent a VA examination in January 2012. Although the examiner noted in the examination report that the Veteran was treated during service for left knee complaints, the examiner opined that the Veteran's left knee disability is likely not related to service because the Veteran did not cite a specific left knee injury from service. In an addendum opinion obtained in December 2012, the VA examiner also only noted two injuries to the Veteran's left knee during service before finding that the Veteran had not suffered an acute (recurrent or traumatic) injury to the left knee cartilage. As such, the VA examiner found that the Veteran's left knee degenerative joint disease is not related to any injury that occurred during service. However, in the August 2019 remand, the Board did not find either VA opinion to be adequate as they appear to be based on an incomplete review of the Veteran's STRs. Moreover, neither examiner supported their negative finding with an adequate medical rationale. See Nieves, at 30204. Accordingly, VA obtained an additional addendum opinion in December 2016; however, the examiner only addressed the issue of secondary service connection. Also, the examiner only provided a general literature review and did not specifically discuss the Veteran's left knee disorder in relation to his service-connected disability. Accordingly, the Board remanded the claim once again to obtain an adequate opinion with which to adjudicate the claim. While addendum opinions were obtained in December 2019 and July 2020, the Board finds these opinions similarly problematic to the prior opinions. In this regard, the December 2019 examiner stated that the Veteran sought treatment for left knee pain only once during his service. As noted above, the Board has already acknowledged that the Veteran sought treatment at least five times and received a left knee diagnosis during his time in military service. Accordingly, the Board cannot rely on this opinion, as it is based on an inaccurate factual premise and reflects an incomplete review of the relevant evidence of record. Furthermore, the July 2020 opinion was conclusory and simply provided a negative nexus due to a lack of treatment during service for arthritis, as distinguished from knee injury or pain. Finally, neither opinion adequately addressed whether the Veteran's degenerative left knee condition began within a year of separation from service or is caused or aggravated by his right knee disability. In this regard, the July 2020 examiner again discussed at length the general likelihood of any one knee disability affecting the opposing joint, as well as the general impact of obesity on the development of degenerative knee disorders. However, such did not specifically address the lay statements and medical history of the Veteran, as was required in the August 2019 remand. However, the Veteran also submitted a positive medical opinion connecting the Veteran's current left knee disorder with his military service. Specifically, the Veteran's private physician noted his report of experiencing left knee pain since service, as supported by multiple STRs documenting chronic left knee pain during service. Furthermore, the private treatment provider stated that the Veteran's left knee disability is most likely due to the injury to the right knee, and resultant meniscectomy, during service. In offering this opinion, the examiner cited specific STRs, addressed lay statements from the Veteran, noted the current diagnosis of left knee degenerative arthritis post-arthroplasty, and explained that the Veteran's bilateral knee problems most likely stemmed from an in-service injury that resulted in both the right-knee meniscectomy and the subsequent left-knee pain, degeneration, and need for a replacement. As noted above, the July 2013 private opinion discussing both the Veteran's low back and knee issues was deemed inadequate in the August 2019 Board remand. However, upon further review of the record, the Board finds that such opinion, when considered with all other probative evidence of record, is sufficient to support a grant of service connection for a left knee disorder. In this regard, the opinion is highly probative, as the private treatment provider considered all of the pertinent evidence of record, to include the statements of the Veteran, and provided a complete rationale, relying on and citing to the records reviewed. The examiner also offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two for the instant claim. See Nieves, at 295; Stefl, at 124. Finally, this probative opinion is consistent with the Veteran's competent reports that he has experienced the left knee symptomatology since the onset of recurrent left knee pain, edema, and crepitus during service. Accordingly, in light of the Veteran's in-service treatment for left-knee pain and diagnosis of patellofemoral syndrome, his current diagnosis of degenerative joint disease of the left knee, status post-arthroplasty, and the favorable July 2013 opinion, the Board again resolves all doubt in favor of the Veteran and finds that his currently diagnosed left knee condition is, as likely as not, related to his military service. Consequently, service connection for the left knee disorder is warranted. A. ADAMSON Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Breckenridge 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.