Citation Nr: 21013681 Decision Date: 03/10/21 Archive Date: 03/10/21 DOCKET NO. 16-00 800 DATE: March 10, 2021 ORDER Entitlement to service connection for hypertension is granted. REMANDED Issue of entitlement to service connection for bilateral pes planus is remanded. Issue of entitlement to service connection for a gynecological disorder is remanded. FINDING OF FACT The evidence is in at least relative equipoise as to whether the Veteran’s hypertension was incurred or otherwise related to service. CONCLUSION OF LAW The criteria for entitlement to service connection for hypertension have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from January 1993 to May 1993, April 2002 to December 2002, February 2006 to September 2008, April 2010 to May 2010, and October 2011 to December 2011. This appeal to the Board of Veterans’ Appeals (Board) arose from a March 2014 rating decision issued by the Department of Veterans Affairs (VA). See March 2014 Notice of Disagreement (NOD); November 2015 Statement of the Case (SOC); January 2016 Substantive Appeal (VA Form 9). In September 2018, the Board remanded the claims for further development. September 2018 Board decision. In December 2019, the Board remanded the claims again for further development. December 2019 Board decision. The Agency of Original Jurisdiction (AOJ) developed the evidence and continued the denial of the Veteran’s claims. August 2020 Supplemental Statement of the Case (SSOC). The claims are now back before the Board. 1. Entitlement to service connection for hypertension. The Veteran asserts entitlement to service connection for hypertension. The Veteran relates that she had elevated blood pressure during service. September 2019 Correspondence. Service connection may be established for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. Service connection is established when there is competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). Service connection may also 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). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). In this case, in resolving any reasonable doubt in favor of the Veteran, the Board finds that the Veteran’s hypertension was incurred during service. The evidence supports that the Veteran’s hypertension is current disability. See June 2019 VA examination for hypertension. Service treatment records show that the Veteran had several instances of elevated blood pressure throughout her third period of active duty that ranged from 133/79 to 155/90. See, e.g., September 2006 Service treatment record; November 2006 Service treatment record; December 2006 Service treatment record; March 2007 Service treatment record; March 2008 Service treatment record. The January 2020 VA examiner opined that under the recent guidelines issued by the American College of Cardiology, Stage 1 hypertension is diagnosed with reasons of 130-139/80-89. January 2020 VA examination medical opinion. The evidence supports that the Veteran’s hypertension was incurred during her period of service from February 2006 to September 2008. The Board notes that the June 2019 VA examiner opined that the Veteran’s current hypertension was less likely than not incurred in or otherwise related to service, but that the examiner appeared to be aware of only one elevated blood pressure reading in 2008 and indicated that additional instances of elevated blood pressure may support finding a diagnosis of hypertension during service. See June 2019 VA examination for medical opinion. The Board also recognizes that the Veteran’s service treatment providers did not diagnose the Veteran with hypertension at that time and, instead, diagnosed her with elevated blood pressure. See November 2006 Service treatment record; March 2008 Service treatment record. However, as explained by the January 2020 VA examiner, more recent medical guidelines have determined that a diagnosis of hypertension is warranted with blood pressure readings starting at 130/80. The Board, thus, finds that the evidence is in at least relative equipoise as to whether the Veteran’s current hypertension was incurred in service. Accordingly, entitlement to service connection for hypertension is warranted. REASONS FOR REMAND 1. Issue of entitlement to service connection for bilateral pes planus is remanded. Unfortunately, there has not been substantial compliance with the Board’s previous remand directives regarding the issue of entitlement to service connection for bilateral pes planus. The December 2019 Board decision remanded the claim and directed that the AOJ schedule the Veteran for a VA examination to determine the nature and etiology of the her pes planus. On remand, medical opinion was obtained, but a VA examination was not performed. See February 2020 VA examination medical opinion. The Board recognizes that the February 2020 VA examiner appears to concede pes planus as a condition preexisting service, but a VA examination is needed to reconcile the June 2018 private medical opinion from M D, PT, DPT, which found the Veteran to have pes planus symptoms such as marked pronation of both feet, with the July 2019 VA examiner’s finding of no objective evidence of pes planus in either foot. June 2018 Foot conditions disability benefits questionnaire; July 2019 VA examination medical opinion. An evaluation of the current severity of the Veteran’s pes planus may be helpful prior to determining that there was no aggravation of her pes planus. In addition, the February 2020 VA examiner remarked that ligamentous laxity in the plantar fascia or other support plantar ligaments may contribute to acquired pes planus. February 2020 VA examination medical opinion. The June 2018 opinion from Dr. M D opined that the Veteran’s service connected foot disabilities resulted in plantar fasciitis. June 2018 Foot conditions disability benefits questionnaire. Clarification as to whether the Veteran’s service connected disabilities cause plantar fasciitis and, if so, whether this proximately caused or aggravated the Veteran’s pes planus is needed. The Board finds that a remand is warranted. 2. Issue of entitlement to service connection for a gynecological disorder is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for a gynecological disorder. The January 2020 VA examiner opined that it is less likely than not that the Veteran’s dysmenorrhea and menorrhagia was incurred in or caused by service because there is no evidence of menstrual irregularity during or within a year of discharge from service. However, the Veteran noted in her August 1997, May 2001, and January 2005 Report of Medical History that she has had a change in mensural pattern. While these reports were not during a period of active duty, they do suggest that the Veteran may have had a condition preexisting her later periods of service and an opinion about aggravation would be needed. The Board finds that a remand is warranted. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination by an appropriate medical professional to determine the nature and etiology of her claimed pes planus. The examiner must review the claims file. For each requested opinion, the examiner should provide detailed rationale and citation to evidence if record or medical literature, if possible. (a) After examining the Veteran, state whether the examination supports that she has pes planus. The VA examiner must discuss the August 1997 Report of Medical Examination, which noted moderate pes planus as a defect. The VA examiner must also discuss the June 2018 foot conditions disability benefits questionnaire, which found marked pronation in the Veteran’s feet, and the July 2019 VA examination medical opinion that found no evidence of pes planus. (b) If the Veteran has a current disability of pes planus, the examiner must specifically opinion on whether pes planus preexisted any of her periods of active duty. If pes planus preexisted a period of active duty, the examiner should state whether there was any increase in severity and, if so, whether is was clearly and unmistakably due to natural progression. (c) If the Veteran has a current disability of pes planus that did not preexist a period of active duty, the examiner should opine as to whether it least as likely as not was incurred in or is otherwise directly related to service? (d) If the Veteran has a current disability of pes planus that did not preexist a period of active duty nor is directly related to service, the examiner should opine as to whether her pes planus was proximately due to, the result of, or aggravated by a service connected disability. The examiner should specifically consider and discuss the February 2020 VA examiner’s opinion that list contributing factors to acquired pes planus and the June 2018 foot conditions disability benefits questionnaire that indicates her service connected disabilities cause plantar fasciitis. (e) If the Veteran has a current disability of pes planus that was not incurred in or otherwise related to service, the examiner should, if possible, opine on the likely cause of her pes planus. 2. Obtain an addendum opinion from an appropriate medical professional to determine the nature and cause of the Veteran’s gynecological disorders, including dysmenorrhea and menorrhagia. If the medical professional determines that it is necessary, schedule the Veteran for a VA examination. The medical professional should respond to the following: (a) Did the Veteran’s current gynecological disorders preexist any of her periods of active duty? If so, the examiner should state whether there was any increase in severity and if the increase was clearly and unmistakably due to natural progression. The examiner should consider and discuss the August 1997, May 2001, and January 2005 Reports of Medical History in which the Veteran noted she had a change in mensural pattern. (b) If the Veteran’s current gynecological disorders did not preexist service, is it at least as likely as not (a 50 percent or greater probability) that it began in (or is otherwise related to) the Veteran’s military service? The examiner should consider and discuss the Veteran’s lay testimony and assertions regarding any pertinent complaints and symptoms. (c) If the Veteran’s current gynecological disorders were not incurred in or otherwise related to service, the examiner should, if possible, opinion on the likely cause of her gynecological disorders. R. FEINBERG Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Lin 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.