Citation Nr: 21014057 Decision Date: 03/11/21 Archive Date: 03/11/21 DOCKET NO. 15-40 958 DATE: March 11, 2021 ORDER New and material evidence having been submitted, reopening of the claim of entitlement to service connection for a back disability is granted. Entitlement to service connection for degenerative arthritis of the lumbar spine is granted. REMANDED Entitlement to service connection for hypertension, to include as secondary o service-connected posttraumatic stress disorder (PTSD) and/or sleep apnea, is remanded. FINDINGS OF FACT 1. In a September 2012 decision, service connection for a back disability was denied. 2. The evidence associated with the claims file since the September 2012 decision is not cumulative or redundant and raises a reasonable possibility of substantiating the claim for service connection for a back disability. 3. Resolving reasonable doubt in his favor, the Veteran’s degenerative arthritis of the lumbar spine was incurred during active service. CONCLUSIONS OF LAW 1. The criteria for reopening a previously denied claim of service connection for a back disability are met. 38 U.S.C. § 5108 (2018); 38 C.F.R. § 3.156 (2019). 2. The criteria for service connection for degenerative arthritis of the lumbar spine are met. 38 U.S.C. §§ 1110, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from November 2004 to July 2005, from March 2013 to April 2014, and from October 2017 to September 2020. He also had periods of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA) with Connecticut National Guard and Army Reserve. This case comes before the Board of Veterans’ Appeals (Board) on appeal from an April 2015 rating decision issued by a Regional Office (RO) of the Department of Veterans Affairs (VA). In February 2021, the Veteran testified before the undersigned Veterans Law Judge. A transcript of the hearing is of record. Claim to Reopen – Back Disability In a final September 2012 decision, the RO denied service connection for a back disability because the evidence did not show that the Veteran had a current disability. The Board finds that new and material evidence has been received to reopen the claim of service connection for a back disability. Later records, including a July 2014 VA examination report, show that the Veteran was diagnosed with degenerative arthritis of the spine. The Board finds that evidence new and material. Therefore, the claim is reopened. Service Connection – Back Disability The Veteran maintains that he injured his back while playing football during Officer Candidate School in 1987 or 1988. He states that he has had recurrent back pain since the injury and that it has progressively worsened and has been aggravated by later periods of active service. The Veteran’s service treatment records are unremarkable for a football injury in 1987 or 1988. During the Board hearing, he stated that he went to sick call, but that there was apparently no record of it. A July 1987 private treatment record indicated that the Veteran reported that he twisted his back during a football game. It was noted that he had no previous back problems at all. In October 1987, he complained of right-sided lumbar pain after playing football over the weekend. The assessment was right-sided sacroiliitis. Statements received from R.R. and F.D. in February 2016, indicated that the Veteran injured his back while playing football during physical training in Officer Candidate School in 1987, and the he has had back problems since that injury. The Veteran’s service personnel records indicated that he attended Officer Candidate School for from May 1987 to July 1988. Following the 1987 injury, treatment records show that the Veteran has had repeated complaints of back pain. In December 2007, it was noted that X-rays were normal and that the condition was likely muscular in nature. An April 2012 private treatment record noted a history of lumbar disc disease and sacroiliitis; however, there are no X-rays of the spine confirming the diagnosis at that time. An August 2012 VA examination report indicated that the Veteran complained of low back pain. Range of motion of the thoracolumbar spine was normal. There was mild pain on palpation of his right paravertebral soft tissues. The examiner stated that he could not identify a causal condition for the Veteran’s subjective low back pain and that it was less likely than not that the claimed condition was incurred in or caused by the claimed in-service injury. An April 2013 service treatment record indicated that the Veteran complained of left-sided sacroiliitis that radiated across his lower back. He stated that he had had the pain since 1988 and was ready to get it fixed. He stated that he saw a chiropractor off base, which had temporarily improved his symptoms, but that the symptoms always came back. A June 2013 X-ray report noted an impression of degenerative disease of the lumbar spine. A July 2014 VA examination report noted that the Veteran had a diagnosis of degenerative arthritis of the spine. In April 2015, the examiner noted that private treatment records showed diagnoses of lumbar disc disease and sacroiliitis prior to active service in March 2013 and that it was less likely than not that those conditions were aggravated during active service. The examiner noted that the Veteran was treated multiple times for back pain during active service but that there were no new injuries or events noted. A September 2017 VA examination report also noted a diagnosis of degenerative arthritis of the spine. The examiner opined that the Veteran’s current back condition was less likely related to the football injury he sustained in July 1987 and was more likely related to age, occupation, and cumulative injuries. In this case, the first indication of arthritis confirmed by X-ray was in June 2013, during active service. Although private treatment records diagnosed the Veteran with lumbar disc disease and sacroiliitis prior to active service, those records do include any X-ray evidence findings confirming a diagnosis of arthritis. The July 2014 VA examiner opined that lumbar disc disease and sacroiliitis were not aggravated during service but made no mention of arthritis. The September 2017 VA examiner opined that the arthritis was not due to the football injury but was the result of other factors. The examiner did not address whether arthritis was incurred during service. Therefore, the VA examiners’ opinions have little, if any, probative value. In this case, the most probative evidence indicates that the Veteran’s degenerative arthritis was first confirmed by X-ray during active service in June 2013. Therefore, resolving reasonable doubt in his favor, the Board finds that service connection for degenerative arthritis of the lumbar spine is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). REASONS FOR REMAND The Board finds that additional development is required before the remaining claim on appeal is decided. In this case, the Veteran’s hypertension was first diagnosed during civilian life in July 2009. During the Board’s February 2021 hearing, he stated that his blood pressure medications had to be increased during his most recent period of active duty from October 2017 to September 2020. Alternative, he asserts that his service-connected depression and sleep apnea have contributed to his hypertension. The Veteran’s service treatment records for his most recent period of active service from July 2019 to September 2020 have not been obtained. Therefore, a remand is necessary to obtain those records. In addition, another VA examination and medical opinion should be obtained to address whether the Veteran’s hypertension was aggravated during his most recent period of active service or by his service-connected PTSD and/sleep apnea. Also, any outstanding current VA and private treatment records should be obtained. The matters are REMANDED for the following action: 1. Obtain any outstanding service treatment record and associate them with the claims file, including from the Veteran’s most recent period of active service from July 2019 to September 2020. 2. Identify and obtain any pertinent, outstanding VA and private treatment records and associate them with the claims file. 3. Then, schedule the Veteran for a VA examination by an examiner with appropriate expertise to determine the nature and etiology of his hypertension. Any indicated studies should be performed. Based on the examination results and a review of the record, the examiner provide an opinion as to whether it is at least as likely as not (50 percent probability or better) that any currently present hypertension is etiologically related to the Veteran’s active service or was aggravated during a period of active service. The examiner should also provide an opinion as to whether it is at least as likely as not (50 percent probability or better) that any currently present hypertension was caused or is aggravated by the Veteran’s service-connected PTSD and/or sleep apnea. A rationale for all opinions expressed must be provided. 4. Confirm that the VA examination report and all opinions provided comport with this remand and undertake any other development found to be warranted. (Continued on the next page)   5. Then, readjudicate the issue remaining on appeal. If a decision is adverse to the Veteran, issue a supplemental statement of the case and allow appropriate time for response. Then, return the case to the Board. Kristin Haddock Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Mishalanie, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.