Citation Nr: 21005318 Decision Date: 02/01/21 Archive Date: 02/01/21 DOCKET NO. 14-02 842 DATE: February 1, 2021 ORDER Entitlement to service connection for an acquired psychiatric disorder, to include depression and an anxiety disorder and as secondary to bilateral pes cavus, chronic right ankle pain, or low back pain is denied. Entitlement to service connection for a heart disorder, to include as secondary to bilateral pes cavus, chronic right ankle pain, low back pain, or an acquired psychiatric disorder is denied. Entitlement to service connection for hypertension, to include as secondary to bilateral pes cavus, chronic right ankle pain, low back pain, or an acquired psychiatric disorder is denied. Entitlement to service connection for headaches, to include as due to undiagnosed illness and as secondary to bilateral pes cavus, chronic right ankle pain, low back pain, or an acquired psychiatric disorder is denied. FINDINGS OF FACT 1. The Veteran’s acquired psychiatric disorders did not have an in-service onset, are not the result of, or otherwise related to active military service, nor was any of his disorders caused or aggravated by his service-connected disabilities. 2. The preponderance of the evidence of record is against finding that the Veteran has had a heart disability at any time during or approximate to the pendency of the claim. 3. The Veteran’s hypertension preexisted service in February 1991 and was not aggravated beyond the normal progress of the disorder during active service. 4. The Veteran’s migraine headaches did not have an in-service onset, are not the result of, or otherwise related to active military service, nor was his headache disorder caused or aggravated by his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for service connection for an acquired psychiatric disorder, to include depression and an anxiety disorder as secondary to bilateral pes cavus, chronic right ankle pain, or low back pain are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 2. The criteria for service connection for a heart disorder, to include as secondary to bilateral pes cavus, chronic right ankle pain, low back pain, or an acquired psychiatric disorder are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 3. The criteria for service connection for hypertension, to include as due to service or as secondary to bilateral pes cavus, chronic right ankle pain, low back pain, or an acquired psychiatric disorder are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 4. The criteria for service connection for headaches, to include as due to undiagnosed illness and as secondary to bilateral pes cavus, chronic right ankle pain, low back pain, or an acquired psychiatric disorder are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from February 1991 to February 1995. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a November 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). These matters were previously remanded by the Board in December 2012, February 2018 and April 2020. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). In addition, for Veterans who have served 90 days or more of active service after December 31, 1946, there is a presumption of service connection for certain chronic diseases, including psychoses, if the disability is manifest to a compensable degree within one year of discharge from service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word “chronic.” Continuity of symptomatology after discharge is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic as per 38 C.F.R. § 3.309(a)). Service connection may be granted, on a secondary basis, for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995) (holding that service connection on a secondary basis requires evidence sufficient to show that the current disability was caused or aggravated by a service-connected disability). In order to prevail under a theory of secondary service connection, there must be: (1) evidence of a current disorder; (2) evidence of a service-connected disability; and, (3) medical nexus evidence establishing a connection between the service-connected disability and the current disorder. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Preexisting Disabilities Every Veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). “When no preexisting condition is noted upon entry into service, the veteran is presumed to have been sound upon entry. The burden then falls on the government to rebut the presumption of soundness by clear and unmistakable evidence that the Veteran's disability was both preexisting and not aggravated by service.” Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). “Clear and unmistakable evidence” is an “onerous” evidentiary standard, requiring that the preexistence of a condition and the no-aggravation result be “undebatable.” Cotant v. Principi, 17 Vet. App. 116, 131 (2003); Quirin v. Shinseki, 22 Vet. App. 390, 396 (2009) (noting that clear and undebatable means that the evidence cannot be misinterpreted or misunderstood). In explaining the meaning of an increase in disability, the Court has held that “temporary or intermittent flare-ups during service of a preexisting injury or disease are not sufficient to be considered ‘aggravation in service’ unless the underlying condition, as contrasted to symptoms, is worsened.” See Hunt v. Derwinski, 1 Vet. App. 292, 297 (1992); see also Davis v. Principi, 276 F.3d 1341, 1346 (Fed. Cir. 2002) (explaining that, for non-combat veterans, a temporary worsening of symptoms due to flare ups is not evidence of an increase in disability). However, the increase need not be so severe as to warrant compensation. See Browder v. Derwinski, 1 Vet. App. 204, 207 (1991). Once the evidence has been assembled, it is the Board’s responsibility to determine whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. §§ 3.102, 4.3. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. The Board must analyze the credibility and probative value of the evidence, account for the persuasiveness of the evidence, and provide reasons for rejecting any material evidence favorable to the claimant. Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff’d per curiam, 78 F.3d 604 (Fed.Cir.1996). The Board assesses both medical and lay evidence. In addressing lay evidence and determining its probative value, if any, attention is directed to both competency (“a legal concept determining whether testimony may be heard and considered”) and credibility (“a factual determination going to the probative value of the evidence to be made after the evidence has been admitted”). See Layno v. Brown, 6 Vet. App. 465, 469 (1994). 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) (providing that a Veteran is competent to report on that of which he or she has personal knowledge). 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. See 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). The benefit of the doubt rule provides that a veteran will prevail in a case where the positive evidence is in a relative balance with the negative evidence. Therefore, the Veteran prevails in a claim when (1) the weight of the evidence supports the claim or (2) when the evidence is in equipoise. It is only when the weight of the evidence is against the claim that the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to service connection for an acquired psychiatric disorder. The Veteran contends that he has an acquired psychiatric disorder which is related to his service or his service-connected disabilities. He has also asserted that his service-connected disabilities have impacted him psychologically, reduced his ability to reduce stress through activity, and affected his mood. Because the Veteran has not raised, and the record does not reasonably raise, entitlement to direct service connection, the Board’s adjudication will consider only entitlement to secondary service connection. Turning to the evidence of record, service treatment records are silent for any complaints or treatment for a psychiatric condition. VA treatment records reflect that the Veteran has been diagnosed with insomnia, adjustment disorder with mixed features, and anxiety. In a September 2010 VA psychiatric opinion, the VA psychiatrist noted that Notes indicate this is for stress related to circumstances at work and not due to any medical condition. Therefore, all available evidence indicates that the veteran’s diagnosed mental health condition is not related to his service-connected medical conditions. There is no cal scientific or research evidence to support the veteran’s contention that his service-connected medical conditions as stated have caused any mental disorder. Thus, it is not likely that any claims of depression or anxiety have been caused by his service-connected medical conditions. In December 2012, the Veteran filed a workers’ compensation claim for “Stress, Anxiety, and Depression” that arose as the Veteran “was undergoing daily in the USPS Environment” and as a result of being “issued a proposed letter of warning of lieu of time-off suspension.” During a May 2019 VA examination, the examiner diagnosed the Veteran with adjustment disorder with mixed anxiety and depressed mood (mixed features) and a separate diagnosis of unspecified anxiety disorder. The examiner reviewed the claims file and determined that the Veteran’s acquired psychiatric disorder was less likely than not etiologically related to service or his service-connected disabilities. Specifically, the VA examiner opined that Based on record review and in-person interview with this veteran, for the reasons laid out below, it is the opinion of this examiner that the veteran’s acquired psychiatric disorders of Adjustment Disorder with mixed anxiety and depressed mood and Anxiety Disorder NOS are less likely than not (less than 50% probability) incurred in or caused by (the) bilateral pes cavus, chronic right ankle pain, or low back pain for which he is service connected. It is the opinion of this examiner that this veteran has current diagnoses consistent with his medical record, of Adjustment Disorder with Mixed anxiety and depressed mood (mixed features) related to ongoing work stressors and his son’s illness and a separate diagnosis of Unspecified Anxiety Disorder including symptoms of panic and rumination which seems to have developed over time in response to life stressors. The VA examiner also opined that there have been clear patterns of waxing and waning of psychiatric symptoms associated with job stress and stress related to his son’s illness, it is the opinion of this examiner that any current or previously diagnosed acquired psychiatric disorders including anxiety and depression are less likely than not (50% or less) proximately due to the veteran’s service-connected bilateral pes cavus, chronic right ankle pain, or low back pain. Prior to the veteran reporting these stressors, his service-related diagnoses of bilateral pes cavus, chronic right ankle pain, or low back pain were not reported to be impacting his occupational or interpersonal functioning. While it is certainly possible that pain and psychiatric symptoms could interact, there is not clear evidence of this occurring in the case of this veteran. There are additional pain-related diagnoses (such as headaches, neck pain) which are not service connected but are also mentioned in the veteran’s reports of pain. The Board affords this opinion great probative value. The probative value of medical opinion evidence is based on the medical expert’s personal examination of the patient, the physician’s knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Whether a physician provides a basis for his or her medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician’s access to the claims folder and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000); Nieves-Rodriguez, 22 Vet. App. 295 (2008); Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Here, the May 2019 opinion was provided by a VA medical professional who possesses the necessary education, training, and expertise to provide the requested opinion. Additionally, the opinion is also shown to have been based on a review of the Veteran’s record and is accompanied by a sufficient explanation as to why the Veteran’s psychiatric conditions were not caused or aggravated by his service-connected disabilities. Furthermore, there is no competing medical opinion of record. As such, the Board finds the May 2019 VA psychiatric opinion to be of great probative value for reasons discussed above. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). The Veteran believes his diagnosed psychiatric conditions are proximately due to or the result of his service-connected disabilities. The Veteran is competent to attest to matters of which he has first-hand knowledge, including experiencing feelings of anxiety. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). However, the Veteran is not competent to diagnose himself with an acquired psychiatric disorder, including anxiety, or to determine the etiology of his diagnosed psychiatric disorders. The Veteran is not competent because he lacks the requisite medical training necessary to formulate an opinion in this regard and the medical matters here are not susceptible to lay observation (unlike a broken leg). Id. Therefore, the Veteran’s medical opinion linking an acquired psychiatric disorder to service or his service-connected disabilities has no probative value. Based on the foregoing, the Board concludes that, while the Veteran has current disabilities of adjustment disorder and an anxiety disorder, the preponderance of the evidence is against finding that the Veteran’s psychiatric disabilities were proximately due to or the result of, or aggravated beyond its natural progression by service-connected disability, and therefore, service connection is not warranted. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). In reaching this decision, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the claim, the doctrine is not for application. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to service connection for a heart disorder. The Veteran contends that he has a heart disorder which is related to his service or his service-connected disabilities. The Veteran’s VA treatment records indicate that he sought treatment for tachycardia and a racing heart. However, the Veteran was not diagnosed with any cardiac condition. In March 2003, the Veteran sought treatment for complaints of chest pain. The treating physician noted an abnormal EKG but attributed the findings to stress. The physician did not diagnose a cardiac condition. The Veteran’s VA treatment records are otherwise silent for any cardiac treatment or diagnosis. In May 2019, a VA examiner evaluated the Veteran and determined that he did not have a heart condition. The VA examiner also noted that Veteran denies a current heart condition. Veteran reports ER visit for palpitations, nonspecific tachycardia, and syncopy. These symptoms due to anxiety and panic attacks. In October 2019, a VA examiner evaluated the Veteran and determined that, while he experienced subjective symptoms of heart palpitations, he did not have a diagnosis of any heart condition. The VA examiner opined that The Veteran does not have a heart condition; therefore, it is not proximately due to or aggravated by the Veteran’s SC bilateral pes cavus, chronic right ankle pain or low back pain. The Veteran is not currently diagnosed with a chronic heart condition. Veteran had episodic ER visits for palpitations, syncope and nonspecific tachycardia that were due to anxiety and panic attacks that resolved without residual. The Veteran does not have a current or previously diagnosed heart condition. Here, the October 2019 opinion was provided by a VA medical professional who possesses the necessary education, training, and expertise to provide the requested opinions. Additionally, the opinion is also shown to have been based on a review of the Veteran’s record and is accompanied by a sufficient explanation as to why the Veteran’s complaints of heart problems were not due to a diagnosed heart disability. Furthermore, there is no competing medical opinion of record. The Board thus finds that the October 2019 opinion is dispositive of the issue at hand. While the Veteran believes he has a current diagnosis of a heart disability, he is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical knowledge and the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. As there is no diagnosis of a current heart disability, service connection is not warranted. In reaching this decision, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the claim, the doctrine is not for application. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 3. Entitlement to service connection for hypertension. The Veteran contends that his hypertension is related to service or has been aggravated by his service-connected disabilities. For VA rating purposes, the term hypertension means that the diastolic blood pressure is predominantly 90 millimeters (mm) or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160 mm or greater with diastolic blood pressure of less than 90 mm. 38 C.F.R. § 4.104, DC 7101, Note 1 (2019). The Veteran has a current diagnosis of hypertension for VA purposes as evidenced by the November 2019 VA examination, which showed the results of three separate blood pressure readings each with diastolic blood pressure over 90 despite medication, and subsequent treatment records. Hypertension is an enumerated condition under 38 C.F.R. § 3.309(a); Walker, 708 F.3d 1331. However, the disability was not shown as chronic during his period of active duty service, did not manifest to a compensable degree within a presumptive period from that period of service, and was not noted in service with attributable continuity of symptomatology. The May 1990 entrance examination report for active service shows the examining physician listed the Veteran’s blood pressure as 130/84. However, no diagnosis of hypertension was provided at the time of the enlistment examination. As the disability was not diagnosed at the time, the Veteran is presumed sound upon entry. 38 U.S.C. §§ 1111, 1132, 1137. As noted, in order to rebut this presumption there must be clear and unmistakable evidence that the Veteran’s disability was both preexisting and not aggravated by service.” Wagner, 370 F.3d at 1096. Concerning pre-existence, in June 2020 the Veteran was afforded a VA DBQ examination for hypertension. Following the evaluation, the VA examiner concluded that the Veteran’s hypertension clearly and unmistakably existed prior to service and was not aggravated beyond its natural progression by an in-service event, injury. The VA examiner noted that Upon medical records review, the Veteran had a blood pressure of 134/84 on his Enlistment Examination performed on 5/18/90 at the Pittsburgh MEPS. According to current guidelines, this reading is in the high blood pressure, or Stage I Hypertension, range. Thus, his hypertension likely preexisted service. Based on this opinion, in particular the examiners assessment that the blood pressure readings noted on enlistment were sufficient to support a diagnosis of hypertension at that time, the Board finds that there is clear and unmistakable evidence that the disability pre-existed the Veteran’s period of service. Next, the Board must determine whether there is clear and unmistakable evidence that the Veteran’s pre-existing hypertension was not aggravated during service. To make this determination, the Board must consider the Veteran’s service treatment records as well as evidence developed after service. The Board notes that aggravation for purposes of entitlement to VA compensation benefits requires more than that a pre-existing disorder become intermittently symptomatic during service. There must be permanent advancement of the underlying pathology. Review of the Veteran’s service treatment records include a September 1992 in-service incident for dizziness. The Veteran’s blood pressure was documented as 145/80. The treating physician noted that the dizziness resulted from a viral illness. In an August 1992 treatment note, the Veteran, following an ankle injury, was documented as having a blood pressure of 122/64. In a July 1993 treatment note, the Veteran, following an ankle injury, was documented as having a blood pressure of 150/92. In an August 1994 treatment note, the Veteran, following an ankle injury, was documented as having a blood pressure of 126/64. In a September 1994 treatment note, the Veteran was documented as having a blood pressure of 149/101. In a September 1994 treatment note, the Veteran was documented as having a blood pressure of 129/84. As such, review of the service treatment records, does not show a permanent worsening of the preexisting hypertension noted at the May 1990 service entrance examination during his period of active service from February 1991 to February 1995. Service treatment records are highly probative of the Veteran’s physical condition during service, as they are the only contemporaneous record of his hypertension, but they should also be considered in light of the record as a whole. Following service and pursuant to the claim on appeal, review of private treatment records shows diagnoses and treatment for hypertension. In an April 1995 treatment note, four months after the Veteran’s separation from service, his blood pressure was documented as 132/71. Similarly, in an April 1995 VA examination, the Veteran’s blood pressure was documented to be 120/85. This evidence does not show a permanent worsening of the Veteran’s hypertension from what was shown at enlistment. Again, six months prior to separation, his blood pressure reading was 129 over 84 and there was no notation of hypertension. The June 2020 VA examiner also opined as to the question of aggravation. The examiner affirmed the Veteran’s current diagnosis of hypertension, and following the examination and review of the claims file, provided the following opinion: According to the Veteran’s Hypertension DBQ performed on 5/26/19, the Veteran’s average blood pressure was 140/87, and he was taking one medication, atenolol, for control. His blood pressure had been stable, and there were no symptoms. If aggravated beyond natural progression, it would be expected that the Veteran's blood pressure would be significantly more elevated in 2019 compared to his entrance exam in 1995, and this was not the case. It would also be anticipated that he would require more than one medication for control. The VA examiner reviewed the claims file, to include the Veteran’s assertions and the September 1992 in-service incident for dizziness, and there is no indication that the examiner was not fully aware of the Veteran’s past medical history or misstated any relevant fact. Moreover, the examiner has the requisite medical expertise to render a medical opinion regarding the Veteran’s hypertension and had sufficient facts and data on which to base a conclusion. Further, there is no contradicting medical evidence of record. As such, the Board finds the December 2019 VA medical opinion to be of great probative value for reasons discussed above. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). The Board generally finds that the Veteran is competent to provide statements regarding what comes to him through his senses, and the Board has considered the statements from the Veteran that his hypertension was aggravated during active service. See Layno v. Brown, 6 Vet. App. 465, 69-70 (1994). However, his current assertions of aggravation of the disability in service are contradicted by the clinical testing and physician findings which was conducted during active service. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (noting that contemporaneous evidence has greater probative value than history as reported by a veteran). Given this fact, the Board accords the Veteran’s arguments limited probative value. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). In sum, the Board finds that the Veteran’s hypertension clearly and unmistakably pre-existed service and that it clearly and unmistakably was not aggravated by service. The Board finds that the medical evidence, particularly the service entrance examination report in May 1990, existing service treatment records, and the June 2020 VA medical opinion outweigh his assertions of worsening during active service and any finding of aggravation during active service. Additionally, the Veteran contends that his hypertension has been aggravated by his service-connected disabilities. As an initial matter, the Veteran does not have an acquired psychiatric disorder which has been determined to be related to his military service or to his service-connected disabilities. Therefore, the Board will only consider secondary service connection based on his bilateral pes cavus, chronic right ankle pain and low back disabilities. Based on the evidence of record, the Board concludes that, while the Veteran has a current disability of hypertension, the preponderance of the evidence is against finding that the Veteran’s hypertension is proximately due to or the result of or aggravated beyond its natural progression by service-connected disability. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). In May 2019, the Veteran was afforded a VA examination for hypertension. Following the evaluation, the VA examiner concluded that the Veteran’s hypertension was not caused or aggravated beyond its natural progression by his service-connected disabilities. The VA examiner opined that The Veteran’s hypertension is not proximately due to or aggravated by the Veteran’s service-connected pes cavus, chronic right ankle pain, or low back pain. There is no known medical literature to support this contention. Per Mayo Clinic, risk factors include age, race, family history, being overweight, not being physically active, using tobacco, drinking too much alcohol, and certain chronic conditions - ie. kidney disease, diabetes, and sleep apnea. The December 2019 VA examiner also opined that Upon medical records review, there is documentation of hypertension in the impression/plan from the Washington CBOC on 11/1/06. It was noted that there was no diagnosis of hypertension in the past, and that this is probably related to his stress and anxiety from his job as a Postmaster at the Canonsburg Post Office. The Veteran was counseled extensively on diet and exercise. He was to continue his Ativan on workdays and discontinue it on the weekends. He was to return to the clinic for a blood pressure check in one month. On 9/17/15, he was taking buspirone 20 mg PO tid and lorazepam 0.5 mg PO daily prn anxiety/panic attacks. On 8/22/16, the Veteran himself stated that his PTSD and mental-related conditions due to stress, anxiety and depression have increased his blood pressure. Stress, in fact, is a risk factor for hypertension and can lead to transient increases in blood pressure. Therefore, it is opined that the Veteran’s hypertension is clinically and mathematically more likely related to his stress and anxiety and less likely than not proximately due to or the result of the Veteran's service connected disabilities to include A) lumbosacral strain, B) chronic right ankle pain, and C) bilateral pes cavus with heel pain. In a June 2020 VA addendum opinion, following a review of the Veteran’s treatment records, the VA examiner concluded that the Veteran’s hypertension was not caused or aggravated beyond its natural progression by his service-connected disabilities. The VA examiner opined that According to the Veteran’s Hypertension DBQ performed on 5/26/19, the Veteran’s average blood pressure was 140/87, and he was taking one medication, atenolol, for control. His blood pressure had been stable, and there were no symptoms. If aggravated beyond natural progression, it would be expected that the Veteran's blood pressure would be significantly more elevated in 2019 compared to his entrance exam in 1995, and this was not the case. It would also be anticipated that he would require more than one medication for control. Hence, it is opined that any currently diagnosed condition related to the Veteran’s claimed hypertension was less likely than not aggravated beyond its natural progression by the Veteran’s service connected disabilities to include A) lumbosacral strain, B) chronic right ankle pain, and C) bilateral pes cavus with heel pain. The Board affords these opinions great probative value. Here, the December 2019 and June 2020 opinions were provided by VA medical professionals who possess the necessary education, training, and expertise to provide the requested opinions. Additionally, the opinions are also shown to have been based on a review of the Veteran’s record and is accompanied by a sufficient explanation as to why the Veteran’s hypertension was not caused or aggravated by his service-connected disabilities. Furthermore, there is no competing medical opinion of record. The Board thus finds that the December 2019 and June 2020 opinions are dispositive of the issue at hand. The VA examiners reviewed the claims file, to include the Veteran’s assertions, and there is no indication that the examiners were not fully aware of the Veteran’s past medical history or misstated any relevant fact. Moreover, the examiners have the requisite medical expertise to render a medical opinion regarding the Veteran’s hypertension and had sufficient facts and data on which to base a conclusion. Further, there is no contradicting medical evidence of record. As such, the Board finds the December 2019 and June 2020 VA medical opinion to be of great probative value for reasons discussed above. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). The Board generally finds that the Veteran is competent to provide statements regarding what comes to him through his senses, and the Board has considered the statements from the Veteran that his hypertension was caused or aggravated by his service-connected disabilities. See Layno v. Brown, 6 Vet. App. 465, 69-70 (1994). However, his current assertions are contradicted by the clinical testing and physician findings. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (noting that contemporaneous evidence has greater probative value than history as reported by a veteran). Given this fact, the Board accords the Veteran’s arguments limited probative value. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Consequently, the Board gives more probative weight to the medical evidence of record. Based on the foregoing, the Board finds the Veteran’s hypertension, which existed prior to service, was not aggravated by active service or by his service-connected disabilities, and service connection is not warranted. In reaching this decision, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the claim, the doctrine is not for application. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 4. Entitlement to service connection for headaches. The Veteran contends that he suffers from headaches which are caused or aggravated by his service-connected disabilities. In an April 2018 correspondence, the Veteran asserts that “the constant migraines and extreme tension headaches are both due to my lumbar sacral disability and the stress and anxiety from my military disabilities.” The Veteran also contends that service connection for his headaches is warranted on the basis of an undiagnosed illness. The Board notes that the Veteran’s military personnel records do not indicate that he served in the Southwest Asia theater of operations. The Veteran’s Certificate of Discharge notes that he did not have any foreign service and there are no awards which indicate service in the Southwest Asia theater of operations. Therefore, the presumption of service connection for an undiagnosed illness or medically unexplained chronic multi-symptom illness is inapplicable to this appeal. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317. Additionally, as discussed below, the Veteran has been diagnosed with migraine and tension headaches. Because the Veteran has not raised, and the record does not reasonably raise, any other basis of entitlement to direct service connection, the Board’s adjudication will consider only entitlement to secondary service connection. Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. The question for the Board is whether the Veteran has a current headache disability that is proximately due to or the result of, or is aggravated beyond its natural progress by service-connected disability of bilateral pes cavus, chronic right ankle pain, or low back pain. As discussed above, service connection is not warranted for an acquired psychiatric disorder, and as such, secondary service connection based on this condition is not warranted. The Board concludes that, while the Veteran has a current headache disability, the preponderance of the evidence is against finding that the Veteran’s headache disability is proximately due to or the result of, or aggravated beyond its natural progression by his service-connected disabilities. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). Post-service VA outpatient records reveal treatment for a headache disability beginning in 2015, with ongoing treatment thereafter. In December 2019, a VA examiner evaluated the Veteran and determined that, while he had a diagnosed headache disorder, the condition was not caused or aggravated by service or service-connected disabilities. The December 2019 VA examiner opined that The Veteran’s migraines and tension headaches are not proximately due to or aggravated by the Veteran’s service-connected bilateral pes cavus, chronic right ankle pain, or low back pain. There is no medical literature to support contention that migraines or tension headaches are the result of Veteran’s SC bilateral pes cavus, chronic right ankle pain and low back pain. The Veteran was diagnosed in 1996 with his SC disabilities and not diagnosed until migraines (2015) and tension headaches (2016). This is 19 years after military separation. In June 2020, a VA examiner evaluated the Veteran and determined that the Veteran’s headache disability was not related to service or his service-connected disabilities. The VA examiner opined that According to the Veteran's medical records, a Neurology Note from the Pittsburgh VAMC on 4/27/18 noted that the Veteran's migraines and tension headaches are under poor control at this point and are likely being exacerbated by medication overuse, poor sleep habits, and anxiety. On 8/22/16, the Veteran himself stated that his PTSD and mental-related conditions due to stress, anxiety and depression caused tension headaches and migraines every day, panic attacks daily, and inability to sleep nightly. Tension headaches occur when neck and scalp muscles become tense or contract. The muscle contractions can be a response to stress, depression, a head injury, or anxiety. Emotional triggers of migraine headaches include stress, depression, anxiety, and excitement. Lack of sleep or altered sleep cycles also contribute to migraines. Thus, clinically and mathematically, the Veteran’s headaches are more likely due to stress and anxiety. Therefore, the Veteran’s medical records support that the claimed headaches are less likely than not proximately due to or the results of the Veteran’s service-connected disabilities. The June 2020 VA examiner also opined that There is no known pathophysiological mechanism by which the back pain, ankle strain and heel pain would aggravate his headaches beyond natural progression. Additionally, these conditions involve completely separate anatomical areas than the neck and scalp muscles contributing to tension headaches and the blood vessels and trigeminal nerve contributing to migraine headaches. If anything, the Veteran’s headaches could have been aggravated beyond natural progression intermittently due to medication overuse causing rebound headaches. Hence, any currently diagnosed condition related to the Veteran’s claimed headaches is less likely than not aggravated beyond its natural progression by the Veteran's service connected disabilities to include A) lumbosacral strain, B) chronic right ankle pain, and C) bilateral pes cavus with heel pain. The Board places great probative weight on the VA examiners’ opinions as the examiners has the medical expertise and training to competently speak to the potential causal relationship between migraine and tension headaches and the Veteran’s service - either by direct causation or aggravation. Here, the October 2019 and June 2020 opinions were provided by VA medical professionals who possesses the necessary education, training, and expertise to provide the requested opinions. Additionally, the opinions are also shown to have been based on a review of the Veteran’s record and is accompanied by a sufficient explanation as to why the Veteran’s tension and migraine headaches are not related to his service or service-connected disabilities. Furthermore, there is no competing medical opinion of record. The Board thus finds that the December 2019 and June 2020 opinions are dispositive of the issue at hand. The Veteran believes his headache disability is proximately due to or the result of a service-connected disability. The Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body, anatomical relationships and pathology. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the skills or medical training to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). In sum, the evidence deemed most probative by the Board establishes that the Veteran’s current headache disorder was not incurred during service. Rather, the most probative evidence demonstrates that his current headache disorder first manifested after service and the VA examiner opined that the Veteran has not described the onset of a chronic disability since service. Additionally, the evidence demonstrates that the Veteran’s headache disorder is not caused or aggravated by his service-connected disabilities. As such, service connection is not warranted on either a direct or a presumptive basis. See 38 C.F.R. § 3.303(b), 3.307, 3.309; Walker, 708 F.3d 1331 (Fed. Cir. 2013). In reaching this decision, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the claim, the doctrine is not for application. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). CHRISTOPHER A. WENDELL Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Michael J. O’Connor 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.