Citation Nr: 21041135 Decision Date: 07/08/21 Archive Date: 07/08/21 DOCKET NO. 16-57 242 DATE: July 8, 2021 ORDER Entitlement to service connection for hypertension, claimed as secondary to the service-connected posttraumatic stress disorder (PTSD), is denied. REMANDED Entitlement to service connection for degenerative arthritis of the spine, cervical strain (claimed as neck condition) is remanded. Entitlement to service connection for bilateral carpal tunnel syndrome is remanded. FINDING OF FACT Hypertension is not caused or aggravated by service-connected PTSD. CONCLUSION OF LAW Hypertension is not proximately due to, or aggravated by, service-connected PTSD. 38 U.S.C. §§ 1131, 5017; 38 C.F.R. §§ 3.303, 3.310(a). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from October 1987 to May 1995. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2014, December 2015, and August 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Board acknowledges that in November 2016, October 2007, and January 2008 the Veteran requested a Board hearing for the carpal tunnel syndrome, hypertension, and neck, respectively. However, in March 2020, the Veteran's attorney submitted correspondence indicating the Veteran is waiving the request for a Board hearing. As such, the Board will proceed with the merits of the appeal. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). In general, service connection requires: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be established on a secondary basis for a disability that is shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Id.; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). VA regulations require that hypertension or isolated systolic hypertension be confirmed by readings taken two or more times on at least three different days. For compensation purposes, hypertension means that the diastolic blood pressure is predominantly 90mm or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm or greater with a diastolic blood pressure of less than 90mm. 38 C.F.R. § 4.104, Diagnostic Code 7101. 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; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. 1. Entitlement to service connection for hypertension The Veteran claims his hypertension is related to the service-connected PTSD. Specifically, in a January 2020 brief the Veteran's attorney argued the PTSD symptoms preceded his hypertension diagnosis, although he was not formally diagnosed with PTSD until many years after the hypertension diagnosis. For the reasons discussed below, the Board finds the evidence weighs against a finding that the Veteran's current disability is secondary to his service-connected PTSD. Therefore, service connection is not warranted. Service treatment records (STRs) do not reflect any symptoms, diagnosis, or treatment for hypertension. In service the Veteran had the following blood pressure readings: 110/80 (June 1991), 130/88 (June 1991), 120/68 (June 1991), 120/88 (November 1991), 110/60 (February 1993), 110/60 (May 1993) 136/92 (April 1994). Post service, a December 2015 VA examination report indicated review of the Veteran's claims file, recounted the Veteran's history, and recited his complaints. It was noted the Veteran was diagnosed with hypertension in 1995. The Veteran reported he started taking medication in 1995 with a private physician. The examiner opined the Veteran's hypertension is less likely than not proximately due to or the result of the Veteran's service-connected condition. It was reasoned, the Veteran's hypertension is well controlled although he had an elevated reading during the examination. Also, the examiner noted, Hypertension is a vascular condition which is not caused by PTSD but isolated elevations can occur due to depression, anxiety, lack of sleep, etc. These are isolated readings and would not be considered chronic in nature. Medications to control hypertension address the vascular, cardiac, and renal systems. They do not address an individual's mental health. For this particular Veteran [the] hypertension diagnosis was made well before the diagnosis of PTSD. A June 2017 VA examination addendum report was requested. The examiner opined the Veteran's hypertension is less likely than not proximately due to or the result of the Veteran's service-connected condition. It was reasoned, Hypertension is a very common condition, affecting persons with or without PTSD, with or without any mental health condition. If PTSD was perhaps causing him to have high blood pressure, ... it would be manifest proximal to the time of the stressor, or at least in the years following. Lacking such data, the probability of PTSD being tethered to [hypertension] becomes lessened. The statement of symptoms of PTSD being present prior to diagnosis of hypertension is not inaccurate. This does not necessarily mean a causative relationship. The posited hypothesis is not particularly scientific in nature, but rather a speculative one, contending that symptoms A were present prior to condition B, thus A causing / worsening B. Not impossible, but neither a firm link either. One using this argument could just as well claim any condition /symptom, prior to diagnosis of B is causative /worsening; in this instance, PTSD is being used as the vehicle as such would grant [service connection]. Meanwhile, [hypertension] being a very common condition as mentioned, and [the] Veteran has a family history thereof. The examiner also reasoned, The diagnosis of [hypertension] was not an apparent entity, nor treatment consideration at the time of separation. It is noted that [the] Veteran had [a Medical Evaluation Board], to which [hypertension] was not a consideration. The traumas he has been awarded [service connection] for, occurred circa 1998, and 1991. Proximal to this time, particularly as he has described a chronic PTSD, records do not indicate [hypertension]...Further, [hypertension] is not an uncommon condition, persons with or without a mental health condition may have. [The] Veteran has a family history of [hypertension], which is apt to increase his risks. Ergo, his risks of developing [hypertension] are heightened due to family history, there is no clear evidence to indicate [hypertension] was in proximity to stressors at hand; ergo, it would be less likely than not that PTSD is related to him developing [hypertension], and more likely that this is idiopathic, or just part of his family history. Simply stated, although some citations in the medical literature do offer a possible correlation between PTSD and hypertension; the abundance of literate indicates that family history is a much greater risk factor; and the most likely explanation of [the] Veteran's [hypertension] cause is due to family history, a risk factor he was born with...Life events such as family, work stress may offer psychological aspects, lifestyle choices - diet, exercise may influence, and family history is an unescapable inevitable risk factor. Ergo, it is speculative, given current science that PTSD is causing, or worsening [hypertension], given the confounding data at hand. The examiner also reasoned the Veteran's anger, hostility, alcohol use, could have contributed to the hypertension. Also, it was noted, although the previous VA examiner noted the Veteran was diagnosed or treated for hypertension in 1995, there is no medical documentation to confirm this. The Board has reviewed all of the lay and medical evidence of record in conjunction with the applicable laws and regulations and finds the current disability is not related to the service-connected PTSD. In this regard, the Board finds that the June 2017 opinion, discussed above, is the most probative evidence of record. The examiner found the hypertension was not related to the service-connected PTSD. It is supported by an adequate rationale, noting "hypertension is a very common condition. If PTSD was perhaps causing him to have high blood pressure, ... it would be manifest proximal to the time of the stressor, or at least in the years following. Lacking such data, the probability of PTSD being tethered to [hypertension] becomes lessened." Notably, in response to the Veteran's arguments, the examiner found "although some citations in the medical literature offer a possible correlation between PTSD and hypertension; the abundance of literate indicates that family history is a much greater risk factor." It was opined that the most likely explanation of the Veteran's hypertension cause is due to family history, a risk factor he was born with. There are no contrary competent medical opinions. As such, the Board finds the June 2017 VA opinion probative. The Board has reviewed the January 2020 arguments presented by the Veteran's attorney. Notably the Board acknowledges the June 2007 case where the Board granted service connection for hypertension as secondary to PTSD for another Veteran, relying in part on the Federal registry 70 FR 37040 which addressed service connection for atherosclerotic heart disease, hypertensive vascular disease, and stroke in former prisoners of war when they have a PTSD diagnosis. The Board notes summarily, that section of the registry indicated "Veterans who have a longterm history of PTSD have a high risk of developing cardiovascular disease and myocardial infarction, particularly if such Veterans suffer from other major psychiatric disorders or inflammatory diseases in addition to PTSD." However, the Board's prior decision in a different case is binding only with respect to that case. That decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303. Furthermore, the VA examiner addressed medical literature regarding these matters and found the Veteran's hypertension is most likely due to family history, a risk factor he was born with. The Board acknowledges the June 2017 VA examiner noted "the statement of symptoms of PTSD being present prior to a diagnosis of hypertension is not inaccurate." However, the examiner also noted, "this does not necessarily mean a causative relationship. The posited hypothesis is not particularly scientific in nature, but rather a speculative one." Although the Veteran reported in 1995, he was diagnosed with hypertension and placed on medication, the evidence of record does not reflect such diagnosis. Also, the record reflects normal in-service blood pressure readings, with exception to the 136/92 in April 1994 which appears to have been isolated. The only other evidence relating the Veteran's hypertension to the service-connected PTSD is the statements of the Veteran and his attorney. However, these statements alone do not establish a medical nexus. Indeed, while the Veteran and his attorney are competent to provide evidence regarding matters that can be perceived by the senses, they have not been shown to be competent to render medical opinions on questions of etiology. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Barr v. Nicholson, 21 Vet. App. 303 (2007) (lay testimony is competent to establish the presence of observable symptomatology). Accordingly, service connection for hypertension is denied. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not applicable. See 38 U.S.C.§5107(b); 38 C.F.R.§ 3.102; see also Gilbert, 1 Vet. App.at 53-56. REASONS FOR REMAND 1. Entitlement to service connection for degenerative arthritis of the spine, cervical strain. The Veteran claims his neck disability is related to service. In April 1989, STRs reflected complaints of neck swelling for 4 months. The Veteran reported he was shot with a BB gun in the neck 5 years prior. He reported the swelling was intermittent, and it did not hurt except when "messed with." An assessment indicated there was a foreign object in his neck. During a July 1989 examination for the neck, the Veteran reported he has not seen worsening of the neck until recently. revealed no symptoms associated with the neck. The treatment provider indicated there were no symptoms documented in the record at that time. Post service, the Veteran was afforded a VA examination in July 2016. In the July 2016 VA examination report, the examiner indicated review of the Veteran's claims file, recounted the Veteran's history, and recited his complaints. He was diagnosed with degenerative arthritis of the spine. He reported the onset of the condition was in 1995. He thinks the condition could be related to a childhood incident where he was shot in the neck with a BB gun or related to combat training. The examiner opined the neck condition was less likely as not incurred in or caused by the claimed in-service injury, event, or illness. The examiner reasoned, "there are no service treatment records for the Veteran that document the Veteran having or being seen for a neck injury." The Board finds the July 2016 VA examination inadequate. The absence of an in-service treatment is not dispositive as to the question of whether the Veteran's neck disability is related to service. The examiners reliance on the absence of evidence in service is an inadequate rationale. Furthermore, the examiner incorrectly found there was no service treatment records for the neck. Indeed, the record reflects April 1989 neck complaints and a July 1989 neck examination. When VA undertakes to provide a VA opinion, it must ensure that the opinion is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Therefore, a new VA opinion supported by a clear concise rationale that considers all evidence of record, is warranted. 2. Entitlement to service connection for bilateral carpal tunnel syndrome The Veteran claims his bilateral carpal tunnel syndrome is related to his service. Specifically, he alleges the bilateral carpal tunnel syndrome is a result of the repetitive motion and stress of constantly pounding tires with a sledgehammer during active service. STRs for June 1991 reflect one complaint of tingling in his right hand and a sore right arm after prolonged time at the rifle range. An assessment reflected flexor carpi ulnar strain. The Veteran submitted a June 2012 statement from his friend P.M., with whom he served in the military. P.M. recalls the Veteran complaining of wrist pain after working on a car during service. A statement from C.R., another friend, was also submitted. C.R. indicated that, while working on a vehicle with the Veteran, he witnessed the Veteran complain of wrist pain. The Veteran also submitted an August 2015 statement from his friend S.F., with whom he served in the military. S.F. remembers the Veteran complaining of wrist pain and numbness while in Saudi Arabia after busting down a couple loads of tires with a sledgehammer, as S.F. experienced the same pain and numbness. Also, S.F. worked with the Veteran after service and remembers the Veteran would avoid jobs that required beating or excessive pulling. In this case, the Veteran was not afforded a VA examination. There is evidence of a current disability as reflected in the September 2011 medical records. The June 1991 STRs and post service statements in June 2012 and September 2015 establish and event or injury in service. As such, a VA examination is warranted. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). The matters are REMANDED for the following action: 1. Forward the claims file to the examiner who conducted the July 2016 VA examination for an addendum etiology opinion and rationale for entitlement to service connection for a neck disability. If the examiner is unavailable, the claims file should be forwarded to another appropriate examiner to provide the requested opinion and rationale. If the requested opinion cannot be provided without another examination of the Veteran, schedule him for a VA examination with an appropriate examiner. The VA examiner should review the April and July 1989 service treatment records reflecting treatment for a neck condition. The examiner is asked to furnish an opinion with respect to the following question: Is it at least as likely as not (a fifty percent probability or greater) that the Veteran's current neck disability is the result of an injury incurred in or as a result of his period of active duty service? A detailed rationale supporting the examiner's opinions must be provided. Note that the lack of documented treatment in service, while probative, cannot serve as the sole basis for a negative finding. If an opinion cannot be made without resort to speculation, the examiner should so state and provide reasoning as to why a conclusion would be so outside the norm that such an opinion is not possible. Note: The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as against it. 2. Provide the Veteran with a VA compensation examination to ascertain the current nature and etiology of a current bilateral carpal tunnel syndrome. The examiner shall provide an opinion as to the following question: Is it at least as likely as not (a fifty percent probability or greater) that the Veteran's current bilateral carpal tunnel syndrome is the result of an injury incurred in or as a result of his period of active duty service, to include herbicide exposure? A detailed rationale supporting the examiner's opinions should be provided. The rationale for any opinion expressed must be provided. Note that the lack of documented treatment in service, while probative, cannot serve as the sole basis for a negative finding. If an opinion cannot be made without resort to speculation, the examiner should so state and provide reasoning as to why a conclusion would be so outside the norm that such an opinion is not possible. Note: The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as against it. 3. Conduct any other development deemed necessary and then readjudicate the Veteran's claims. The Veteran has the right to submit additional evidence and argument on the matter that the Board has remanded. See Kutscherousky v. West, 12 Vet. App. 369, 372 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded for additional development or other appropriate action by the Board or United States Court of Appeals for Veterans Claims must be handled in an expeditious manner. 38 U.S.C. §§ 5109B, 7112. Katherine Kiemle Buckley Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Jackman, Associate 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.