Citation Nr: 21005436 Decision Date: 02/01/21 Archive Date: 02/01/21 DOCKET NO. 16-06 514 DATE: February 1, 2021 REMANDED Entitlement to service connection for hypertension, to include as secondary to posttraumatic stress disorder (PTSD) and/or due to a chronic multisymptom illness is remanded. Entitlement to service connection for a migraine disability, to include as secondary to PTSD and/or due to a chronic multisymptom illness is remanded. Entitlement to service connection for a right shoulder disability, to include as due to a chronic multisymptom illness is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Marine Corps from May 1999 to August 2003, including service in the Southwest Asia Theater of Operations. The Board sincerely thanks the Veteran for his service to our country. This matter comes before the Board of Veterans’ Appeals (Board) from a June 2013 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). This claim was previously before the Board in October 2018, when the claims were denied. The Veteran appealed the decision to the U.S. Court of Appeals for Veterans Claims (Court). In a September 2019 Joint Motion for Partial Remand (Joint Motion), the Court vacated October 2018 decision, in part, and remanded the current issues on appeal back to the Board for readjudication in accordance with the Joint Motion. A March 2020 Board decision remanded the claims for medical opinions. The Board notes that the Veteran’s service treatment records (STRs) and personnel records show evidence of deployment to Kuwait and Iraq; and in a September 2007 Administrative Decision, VA conceded a PTSD stressor that occurred in Iraq. Based upon the Veteran’s confirmed service in Southwest Asia, the March 2020 Board remand recharacterized the Veteran’s service connection claims to include direct service connection based upon a chronic multisymptom illness. 38C.F.R. §3.31. Unfortunately, there has not been substantial compliance with the Board’s remand directives as none of the April 2020 VA examinations responded to the remand directive requesting an opinion as to whether each disability is related to a chronic multisymptom illness. Another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board also notes service connection for acid reflux was remanded by the Board in October 2018. The claim has not yet returned to the Board for further adjudication and will be addressed in a later decision. 1. Entitlement to service connection for hypertension, to include as secondary to posttraumatic stress disorder (PTSD) and/or due to a chronic multisymptom illness is remanded. The April 2020 clinician diagnosed the Veteran with hypertension and provided as negative nexus opinion. Regarding whether the Veteran’s hypertension is related to service, the clinician stated that review of STRs and the Veteran’s medical record does not show a diagnosis of hypertension in or within one year of service. The clinician further stated that the Veteran was diagnosed with essential hypertension in 2007. Regarding whether the Veteran’s hypertension is due to or aggravated by his service-connected PTSD, the clinician stated that review of current medical literature and research shows no physiologic or biomechanical causal relationship between a mental health condition (PTSD) and a physiologic condition of hypertension. The clinician reasoned that while anxiety states can cause a temporary elevation in blood pressure, they do not cause or permanently aggravate primary or secondary hypertension. The clinician cited UpToDate 2015. However, the clinician failed to address the medical article regarding PTSD and hypertension submitted by the Veteran in July 2013, per the March 2020 Board remand instructions. Finally, the clinician did not consider whether the Veteran’s hypertension is related to a chronic multisymptom illness related to the Veteran’s service in Southwest Asia. Remand is warranted for a supplemental medical opinion. 2. Entitlement to service connection for a migraine disability, to include as secondary to PTSD and/or due to a chronic multisymptom illness is remanded. The April 2020 medical opinion clinician diagnosed the Veteran with cluster headaches and provided a negative opinion. Regarding whether the Veteran’s hypertension is related to service, the clinician stated that, while the Veteran complained of occasional headache while on active duty, there is no evidence of chronic, recurrent or severe headache while on active duty or within one year of separation. Regarding whether the Veteran’s hypertension is due to his service-connected PTSD, the clinician stated that the Veteran has been diagnosed with cluster headaches, not migraine headaches. The examiner reasoned that, while migraine headache has been associated with PTSD in some cases, the veteran has been diagnosed with cluster headache which has not. The clinician did not provide a rationale as to his opinion that the Veteran’s headaches are aggravated by his PTSD. The clinician also failed to address the medical article regarding PTSD and headaches submitted by the Veteran in July 2013, per the March 2020 Board remand instructions. Finally, the clinician did not consider whether the Veteran’s headaches are related to a chronic multisymptom illness related to the Veteran’s service in Southwest Asia. Remand is warranted for a supplemental medical opinion. 3. Entitlement to service connection for a right shoulder disability, to include as due to a chronic multisymptom illness is remanded. The April 2020 clinician provided a negative nexus opinion, and in support of this opinion, the examiner stated the Veteran’s STRs do not show diagnosis or treatment for a shoulder condition in service. The examiner stated that the Veteran does not have any right shoulder pathology. The examiner further stated that, while the veteran has stated he dislocated his right shoulder and has a torn rotator cuff, there is no clinical evidence of either pathology. The March 2020 remand directives requested that the April 2020 clinician diagnose any right should disability, including any resolved right shoulder disabilities. The clinician failed to address the August 2005 diagnosis of right shoulder strain. The Board also notes that the Veteran reported that a 2011 MRI showed he has torn cartilage in the right shoulder. As such, attempts should be made to associate the Veteran’s MRI report with the claims file. Finally, the clinician did not address whether the Veteran’s shoulder symptoms, as shown on earlier VA examinations, are related to a chronic multisymptom illness related to the Veteran’s service in Southwest Asia. Remand is warranted for a supplemental medical opinion. The matters are REMANDED for the following action: 1. Please secure for the record copies of complete updated clinical records (any not already of record) of all VA and/or private treatment the Veteran has received for his disability on appeal. Please ask the Veteran to provide the releases necessary for VA to secure private treatment records. (a.) Please provide the Veteran with the opportunity to disclose the provider of his 2011 shoulder MRI and, if the provider is a private provider, to provide the releases necessary for VA to obtain the 2. After the action requested in paragraph 1 above is complete, please obtain a medical opinion to determine the etiology of the Veteran’s hypertension. The Veteran’s claims-file must be made available to and reviewed by the clinician. Based on review of the entire record, the clinician should provide an opinion that responds to the following: (a.) Whether it is at least as likely as not (a 50% probability or greater) that the Veteran’s hypertension is related to service, including environmental exposures experienced by the Veteran during active duty to include his service in Southwest Asia. (b.) Whether it is at least as likely as not (a 50% probability or greater) the Veteran’s hypertension is due to his service-connected PTSD? The clinician is requested to address the article entitled, Hypertension in relation to post traumatic stress disorder and depression in the US National Comorbidity Survey, submitted by the Veteran in July 2013; and (c.) Please provide an opinion as to whether the Veteran’s hypertension is a medically unexplained chronic multisymptom illness. 3. After the action requested in paragraph 1 above is complete, please obtain a medical opinion to determine the etiology of the Veteran’s headache disorder. The Veteran’s claims-file must be made available to and reviewed by the clinician. Based on review of the entire record, the clinician should provide an opinion that responds to the following: (a.) Whether it is at least as likely as not (a 50% probability or greater) that the Veteran’s headaches are related to service, including environmental exposures experienced by the Veteran during active duty to include his service in Southwest Asia? (b.) Whether it is at least as likely as not (a 50% probability or greater) the Veteran’s headaches are due to his service-connected PTSD? Please address the March 2011 article entitled, The Association between PTSD and Headaches, submitted by the Veteran in July 2013. (c.) Whether it is at least as likely as not (a 50% probability or greater) the Veteran’s headaches are aggravated (any increase in severity) by his service-connected PTSD? Please explain. (d.) Please provide an opinion as to whether the headaches are a medically unexplained chronic multisymptom illness In responding to the above, the clinician is requested to address the following: • October 2002 STR showing in-service treatment for headaches. • May 2003 Post-Deployment Health Assessment showing that the Veteran developed headaches during deployment. • August 2005 migraine headache diagnosis. • January 2005 cluster headache diagnosis. 4. After the action requested in paragraph 1 above is complete, please obtain a medical opinion to determine the etiology of any right shoulder disorder. The Veteran’s claims-file must be made available to and reviewed by the clinician. Based on review of the entire record, the clinician should provide an opinion that responds to the following: (a.) Please identify whether the Veteran has had a right shoulder diagnosis at any time during the pendency of the claim (since December 2011); (b.) Is it at least as likely as not (a 50% probability or greater) that any right shoulder diagnosis is related to service, to include environmental exposures experienced by the Veteran during active duty to include his service in Southwest Asia? (c.) What types of long-term effects can reasonably be expected from a dislocation injury such as the Veteran has described? (d.) What is the likelihood that an in-service dislocation would appear as a cartilage tear on a 2011 MRI? (e.) Please provide an opinion as to whether the shoulder disability pattern is consistent with: (1) an undiagnosed illness, (2) a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology. In responding to the above, the clinician is requested to address the following: • The Veteran’s consistent lay statements that he dislocated his right shoulder during jungle training, a corpsman reduced the injury, and his shoulder healed in 3-4 weeks. • December 2001 VA treatment records showing that the Veteran complained of right shoulder pain for the previous 6 years. • August 2005 VA examination diagnosing the Veteran with right shoulder strain and showing right shoulder limited range of motion. • March 2013 VA examination showing continued right shoulder pain on movement and palpation. The clinician is reminded that absence of contemporaneous treatment records cannot be the sole basis for a negative opinion. The clinician is further reminded that the in-service event or injury need not be the sole cause of the current disability. If the clinician determines that an examination is necessary for the addendum opinion, the Veteran should be scheduled for an appropriate VA examination (or telehealth interview, etc., if an in-person examination is not feasible) to determine the nature and etiology of the disorders on appeal.  The clinician must explain the rationale for all opinions in detail, citing to supporting clinical data and/or medical literature, as appropriate. The clinician should take into consideration that the Veteran is competent to report in service and post-service symptom experiences; other witnesses are competent to report observable symptoms. If the clinician cannot provide an opinion without resorting to speculation, the clinician should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. M. C. GRAHAM Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board O. Halpern 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.