Citation Nr: 22017240 Decision Date: 03/24/22 Archive Date: 03/24/22 DOCKET NO. 18-43 101 DATE: March 24, 2022 ORDER Effective from November 3, 2015, entitlement to an initial 10 percent rating for hypertension is granted. Entitlement to service connection for posttraumatic stress disorder (PTSD) is granted. Entitlement to service connection for temporomandibular disorder (TMD) (also claimed as temporomandibular joint dislocation) is granted as secondary to service-connected PTSD. Entitlement to service connection for a disorder manifested by right knee pain, diagnosed as arthritis, is granted. FINDINGS OF FACT 1. During the entire period on appeal, the Veteran's hypertension has been manifested by a history of diastolic pressure predominantly 100 or more that requires continuous medication for control. 2. The Veteran has been diagnosed with PTSD based on an established, in-service stressor. 3. The Veteran's TMD is attributable to his service-connected PTSD. 4. The Veteran's disorder manifested by right knee pain, diagnosed as arthritis, is at least as likely as not related to his active duty service. CONCLUSIONS OF LAW 1. Effective from November 3, 2015, the criteria for entitlement to an initial 10 percent rating for hypertension have been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.104, Diagnostic Code 7101. 2. The criteria to establish entitlement to service connection for a PTSD have been met. 38 U.S.C. §§ 1101, 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. 3. The Veteran's TMD (also claimed as temporomandibular joint dislocation) is proximately due to, or the result of, his service-connected PTSD. 38 U.S.C. §§ 1101, 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 4. The criteria to establish entitlement to service connection for a disorder manifested by right knee pain, diagnosed as arthritis, have been met. 38 U.S.C. §§ 1101, 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had service in the United States Air Force and Air National Guard. He had a period of active duty for training (ACDUTRA) from February 1982 to May 1982, and a period of active duty from October 2001 to September 2005. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a February 2016 rating decision. The Veteran testified at a Board hearing before the undersigned Veterans Law Judge in March 2021. A transcript from that proceeding is associated with the claims file. The Board notes that the February 2016 rating decision also denied entitlement to service connection for tinnitus, and the Veteran filed a timely notice of disagreement for this issue in February 2017. However, a subsequent November 2017 Decision Review Officer (DRO) decision granted entitlement to service connection for tinnitus. The grant of service connection for this disability constitutes a full award of the benefits sought on appeal. See Grantham v. Brown, 114 F. 3d 1156, 1158 (Fed. Cir. 1997). Entitlement to an initial compensable evaluation for hypertension. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule), found in 38 C.F.R. § Part 4. Disability ratings are intended to compensate impairment in earning capacity due to a service connected disorder. 38 U.S.C. § 1155. The evaluation of a service-connected disorder requires a review of a veteran's entire medical history regarding that disorder. 38 U.S.C. § 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When a reasonable doubt arises regarding the degree of disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7. Evidence to be considered in an appeal from an initial disability rating was not limited to that reflecting the then current severity of the disorder. Fenderson v. West, 12 Vet. App. 119 (1999). In contrast, for an already established service-connected disability, the present disability level is the primary concern and past medical reports do not take precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55 (1994). For both types of increased rating claims, it is possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. See Fenderson, 12 Vet. App. at 126-27; Hart v. Mansfield, 21 Vet. App. 505, 509 (2007). Such separate disability ratings are known as staged ratings. The Veteran has been in receipt of an initial noncompensable evaluation for hypertension effective from November 3, 2015. The disability is rated under 38 C.F.R. § 4.104, Diagnostic Code 7101. Diagnostic Code 7101 provides that a 10 percent rating is warranted when diastolic pressure is predominantly 100 or more or when systolic pressure is predominantly 160 or more, or for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent rating is warranted when diastolic pressure is predominantly 110 or more or systolic pressure is predominantly 200 or more. A 40 percent rating is warranted when diastolic pressure is predominantly 120 or more. A 60 percent rating is warranted when diastolic pressure is predominantly 130 or more. 38 C.F.R. § 4.104, DC 7101. Under Diagnostic Code 7101, "a history of diastolic pressure predominantly 100 or more [that] requires continuous medication for control" refers to blood pressure readings taken before a veteran began medication to control hypertension, and therefore may require analyzing blood pressure readings prior to the period on appeal. See Wilson v. McDonough, No. 19-6020, 2021 U.S. App. Vet. Claims LEXIS 2208 (Dec. 20, 2021). In an October 30, 2001 periodic non fly service examination, the Veteran's blood pressure was noted to be 132/84. The EKG section also noted a normal sinus rhythm. However, the summary of defects and diagnoses noted that the EKG showed a possible old inferior wall myocardial infarction. A separate October 30, 2001 STR indicated that the Veteran was sent to an Army clinic for further evaluation in relation to an abnormal EKG. A November 2, 2002 record from the Ireland Army Community Hospital that appeared to be associated with this STR noted a blood pressure of 132/92. The record stated that the Veteran was to be reevaluated after an Air Force physical, and the record indicated that the Veteran had a related blood pressure of 142/95. The record indicated that there had been a grade 1 fundus change associated with diastolic hypertension. The record also indicated that the Veteran had received sufficient treatment with a beta-blocker to bring the diastolic reading to 85. A November 2, 2001 STR noted that the Veteran brought documentation of an EKG evaluation at an Army clinic, and the evaluation included a reference to hypertension. The record stated that the Veteran was given a 127 SG Form #7, and he elected to obtain a 5-day blood pressure check from a private medical doctor at no expense to the government. A November 2, 2001 Michigan Air National Guard memorandum on a 127SG Form 7 was also included in the STRs regarding a five-day blood pressure check for the Veteran. The memorandum indicated that the five-day blood pressure check was completed when an examinee presented an abnormal blood pressure reading upon physical examination. The memorandum instructed for all blood pressure readings to be recorded on the reverse side and returned by November 15, 2001. A separate document with the readings for the five-day blood pressure check indicated that they were performed at the office of S.S., DO. The blood pressure readings were as follows: (1) 146/102 on November 5, 2001 using the right arm; (2) 138/98 on November 6, 2001 using the left arm; (3) 134/96 on November 7, 2001 using the left arm; (4) 142/100 on November 8, 2001 using the right arm; and (5) 136/96 on November 9, 2001 using the right arm. The average from these readings was 139/98. A November 8, 2001 letter signed by K.F., DO, in the Veteran's STRs stated that the Veteran was seen in her clinic on that date for a reevaluation. K.F. noted that the Veteran was previously evaluated on April 16, 2001, and his blood pressure at that time was 128/82. When he was reevaluated on September 24, 2001, his blood pressure was 124/84. In light of a reading during the last week, K.F. recommended a low dose of an ace inhibitor while the Veteran was under current stressors. A subsequent November 13, 2001 from K.F. stated that the Veteran was seen in her clinic on that date to be evaluated for hypertension. His blood pressure in the office was 130/86 and 128/88. The Veteran had been started on 10 milligrams of Zestril once a day and was asked to follow up in the office in 2 weeks for a recheck. In a subsequent August 2002 Annual Medical Certificate, the Veteran noted that he was currently being treated for normal high blood pressure. The Veteran added that there were no restrictions, and he had started taking Zestril in November 2001. The Veteran separately noted that the Zestril was a daily medication for stress/slightly high blood pressure and opined that it would probably be discontinued after he was deactivated. Later in a September 2005 Report of Medical Assessment, the Veteran reported that he was taking 10 milligrams of Zestril once a day. The Veteran submitted a hypertension Disability Benefits Questionnaire (DBQ) that was completed in March 2014 by S.B., DO. The diagnosis was hypertension, and S.B. indicated that the date of the diagnosis was early 2001 to 2003. S.B. also stated that the Veteran's treatment plan included taking continuous medication for his hypertension without identifying the medication. S.B. did not provide an answer to indicate whether the Veteran had a history of diastolic blood pressure elevation to predominantly 100 or more. The current blood pressure readings noted in the evaluation were 118/87 from March 14, 2013; and 118/78 from September 9, 2013; and 120/84 from February 27, 2014. There were no other pertinent findings or relevant scars, and S.B. stated that the Veteran's hypertension did not impact his ability to work. The Veteran was provided with a VA examination to evaluate his hypertension disability in February 2016. The diagnosis was hypertension, and the date of the diagnosis was 2001. The examiner noted that the Veteran reported being found to have a high blood pressure of 164/104 as part of his annual physical in 2001/2002. He was seen by an outside physician. The blood pressure was also recorded several times over the course of several weeks. The Veteran was diagnosed with hypertension and started on Zestril medication which he continued to use at the present time. The examiner identified this medication in noting that the Veteran's treatment plan included taking continuous medication for his hypertension. The examiner also stated that the Veteran did not have a history of a diastolic blood pressure elevation to predominantly 100 or more. The blood pressure readings included in the examination report were 122/79 on October 6, 2014; 134/83 on November 2, 2015; and 142/90 on February 3, 2016. The average blood pressure reading was 132/84. There were no other pertinent physical findings or complications, and the Veteran did not have related scars. The examiner also stated that the Veteran's hypertension did not impact his ability to work. During the March 2021 Board hearing, the Veteran noted that although his blood pressure was currently under control, he indicated that it was "really high" before he went on medication. At that time, a physician assistant told him it was 164/104. The Veteran indicated that he had not been alerted to high readings prior to that point. He also confirmed that his blood pressure was consistently elevated enough that his providers wanted to put him on medication. The Veteran was sent to an off-base doctor who conducted further testing and started him on the medication; and he reported that his medication had stayed the same since that time. The Veteran also indicated that although he attempted to find the doctor from this period of treatment, the doctor's office was no longer there. The Board notes that the Veteran is competent to relay what a medical provider has told him. See Layno v. Brown, 6 Vet. App. 465 (1994). The Board also finds the Veteran's reported history to be credible as it is consistent with his report from the February 2016 examination indicating that he was initially found to have a blood pressure of 164/104 in 2001/2002. As noted above, two of the readings from the November 2001 5-day blood pressure check showed a diastolic blood pressure of 100 or more. The record indicates that K.F. also recommended for the Veteran to start taking a blood pressure medication in November 2001 in connection with these findings. The examination report and the Veteran's Board hearing testimony collectively reflect that similarly elevated pressures were recorded several times over the course of several weeks before his providers started him on medication to treat his hypertension. In addition, the Veteran provided an explanation for the lack of some of the records of this treatment by testifying that the doctor's office was no longer there. Although the Board has considered the February 2016 VA examiner's finding that the Veteran did not have a history of diastolic pressure predominantly 100 or more, this finding did not appear to consider the Veteran's reported history of high blood pressure before he began taking medication in 2001 or 2002. Based on the foregoing, and affording the Veteran the benefit doubt, the Board finds that there is probative evidence that the Veteran's has a history of diastolic pressure predominantly 100 or more. The February 2016 VA examiner's finding that the Veteran's treatment plan included taking continuous medication for his hypertension also reflects that he requires continuous medication for the control of his hypertension. Consequently, the evidence weighs persuasively in favor of finding the Veteran's hypertension has met the criteria for an initial 10 percent rating under Diagnostic Code 7101 for the entire appeal period. The Veteran has also indicated that he would be satisfied with a 10 percent rating for his hypertension disability. See February 2017 Notice of Disagreement. Therefore, discussion of whether a rating higher than 10 percent is warranted for hypertension is unnecessary. Cf. AB v. Brown, 6 Vet. App. 35, 39 (1993) (a veteran is presumed to be seeking the maximum possible rating unless he indicates otherwise). In light of the evidence discussed above, the Board finds that a 10 percent disability rating for the Veteran's hypertension, but no higher, is warranted for the entire period on appeal. 38 U.S.C. § 5107(b). SERVICE CONNECTION Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (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-the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 38 F.3d 1163, 1167 (Fed. Cir. 2004)). The absence of any one element will result in denial of service connection. Service connection may also be granted for any disease initially diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including arthritis, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309. For the showing of a 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. If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted where a disability is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. 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. Allen v. Brown, 7 Vet. App. 439, 48 (1995) (en banc). As a threshold matter, veteran status must be established as a condition of eligibility for service connection benefits. See Bowers v. Shinseki, 26 Vet. App. 201, 206 (2013). A veteran is a person who served in the active military, naval, or air service and who was discharged or released under conditions other than dishonorable. 38 C.F.R. § 3.1(d). The term "active military, naval, or air service" includes active duty, any period of ACDUTRA during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in line of duty, and any period of inactive duty for training (INACDUTRA) during which the individual concerned was disabled or died from an injury incurred or aggravated in line of duty. 38 U.S.C. § 101 (24); 38 C.F.R. §§ 3.6 (a)-(d). The fact that a claimant has established veteran status for other periods of service does not obviate the need to establish veteran status for the period of ACDUTRA or INACDUTRA on which the claim is based. Mercado-Martinez v. West, 11 Vet. App. 415, 419 (1998). The advantage of certain evidentiary presumptions, provided by law, that assist veterans in establishing service connection for a disability do not extend to those who claim service connection based on a period of ACDUTRA or INACDUTRA. Paulson v. Brown, 7 Vet. App. 466, 470-71 (1995) (noting that the Board did not err in not applying presumptions of sound condition and aggravation to veteran's claim where he served only on ACDUTRA and had not established any service-connected disabilities from that period); McManaway v. West, 13 Vet. App. 60, 67 (1999), vacated on other grounds sub nom; McManaway v. Principi, 14 Vet. App. 275 (2001) (citing Paulson, 7 Vet. App. at 469-70, for the proposition that if a claim "relates to period of [ACDUTRA], disability must have manifested itself during that period; otherwise, period does not qualify as active military service and claimant does not achieve veteran status for purposes of that claim." (emphasis added in McManaway)); see also Biggins v. Derwinski, 1 Vet. App. 474, 479 (1991) (Steinberg, J., concurring). Thus, the evidentiary burden is on the claimant to show that he or she became disabled from an injury or disease incurred in line of duty during ACDUTRA or from an injury incurred in line of duty during INACDUTRA. Entitlement to service connection for PTSD. Similar to the requirements for service connection outlined above, service connection for PTSD requires (1) medical evidence establishing a diagnosis of the disorder, (2) credible supporting evidence that the claimed in-service stressor occurred, and (2) a link established by medical evidence between the current symptoms and an in-service stressor. 38 C.F.R. § 3.304(f). 38 C.F.R. § 4.125(a) provides that all psychiatric diagnoses must conform to the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 38 C.F.R. § 3.304(f). Effective August 4, 2014, VA amended the portion of its Schedule for Rating Disabilities dealing with mental disorders and its adjudication regulations that define the term "psychosis" to remove outdated references to the DSM-IV and replace them with references to the recently updated DSM-5. See 79 Fed. Reg. 45, 094 (August 4, 2014). VA adopted as final, without change, this interim rule and clarified that the provisions of this interim final rule do not apply to claims that have been certified for appeal to the Board or are pending before the Board on or before August 4, 2014. See Schedule for Rating Disabilities - Mental Disorders and Definition of Psychosis for VA Purposes, 80 Fed. Reg. 14,308 (March 19, 2015). The Board notes that the DSM-5 is applicable in the present case. The pertinent regulation provides that, if the evidence establishes that the Veteran engaged in combat with the enemy and that the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. See 38 U.S.C. § 1154(b); 38 C.F.R. § 3.304(f)(1). For stressors unrelated to combat that are not based on fear of hostile military or terrorist activity, credible supporting evidence is necessary in order to grant service connection. Such evidence may be obtained from service records or other sources. See Moreau v. Brown, 9 Vet. App. 389 (1996). The United States Court of Appeals for Veterans Claims (Court) has held that the regulatory requirement for "credible supporting evidence" means that "the appellant's testimony, by itself, cannot, as a matter of law, establish the occurrence of a non-combat stressor." Dizoglio v. Brown, 9 Vet. App. 163, 166 (1996). Therefore, the Veteran's lay testimony, is insufficient, standing alone, to establish service connection. Cohen v. Brown, 10 Vet. App. 128, 147 (1997). Effective July 13, 2010, if a stressor claimed by a veteran is related to the Veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the Veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the places, types, and circumstances of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. For purposes of this paragraph, "fear of hostile military or terrorist activity" means that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, such as from an actual or potential improvised explosive device (IED); vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the veteran's response to the event or circumstance involved a psychological or physiological state of fear, helplessness, or horror. See 75 Fed. Reg. 39843, 39852 (July 13, 2010) (now codified at 38 C.F.R. § 3.304(f)(3)). The Veteran contends that he has PTSD as a result of stressful events that occurred during his active service. The Veteran's service treatment records (STRs) are largely silent for any complaint, treatment, or diagnosis related to PTSD. As noted above, the STRs did include the November 2001 record in which K.F. recommended for the Veteran to take a low dose of an ace inhibitor while he was under current stressors. The Veteran also indicated in the August 2002 Annual Medical Certificate that his use of Zestril medication was for the treatment of stress/slightly high blood pressure. There was no other relevant complaint or diagnosis in the STRs. The Veteran has attributed his claimed PTSD to different in-service stressor events. In a September 2014 Statement in Support of Claim for Service Connection for PTSD, the Veteran detailed that one event occurred during his active duty in May 2002 while he was assigned to the 366/379 Expeditionary Security Forces Squadron from March 2002 to June 2002. The Veteran reported that while he was deployed to Qatar in support of Operation Enduring Freedom at Al Udeid Air Base from March through June 2002, he was involved in an incident where the vehicle search area and main gate were affected by sniper fire. The vehicle search area reported shots fired and then blacked out. The Veteran was at the main gate where they blacked out and then opened the gates and vehicle entrapment area to allow as many personnel as possible onto the installation without incident. Once the inbound personnel were safe and secure, the Veteran took a high vantage point with night vision goggles onto the roof of the gatehouse. Not long after this point, a tower reported that shots were fired in the area. While the Veteran was scanning the area, he was partially exposed, alone, and left with his voice as his only form of communication to reach his partner if the partner was close. The Veteran stated that no deaths or injuries occurred as a result of this incident. However, the Veteran recalled feeling alone, vulnerable, and afraid during this event. The Veteran also reported that as a result of this incident, he had become guarded and hypervigilant, he avoided crowds, and he found that loud noises could sometimes startle or even anger him. During certain situations where the Veteran might feel vulnerable such as a sporting event, the memory of this stressful event came back to him. The Veteran additionally submitted a June 2002 letter that was written to his mother from J.G., a lieutenant colonel in the Air Force, in appreciation for her sacrifice in allowing the Veteran to fight terrorism. J.G. stated that as a member of the 379th Expeditionary Security Forces Squadron, the Veteran was instrumental in providing security for Air Force aircraft and personnel that directly engaged enemy forces during Operation Enduring Freedom and Operation Anaconda. The Veteran's DD 214 for the period of active duty from October 2001 to July 2003 notes that his last duty assignment and major command was the 127th Security Forces Squadron. The DD 214 for this period also reflects that his primary specialty was security police supervisor, and he served at the Al Udeid Air Base in Qatar in support of Operation Enduring Freedom from March 2002 to June 2002. The record indicates that the agency of original jurisdiction (AOJ) attempted to verify this stressor by contacting the Joint Services Records Research Center (JSRRC), and the JSRRC's response was received in May 2018. The JSRRC stated that although they had researched the Operation Iraqi Freedom information available to that agency, they were unable to locate information concerning the stressor incident at Al Udeid Air Base in Qatar in May 2002. The JSSRC advised the AOJ that they might want to coordinate their research with the Veterans Affairs Liaison Officer from the Headquarters United States Special Operations Command who might be able to provide the information they were requesting. However, the Board does not find this response to be relevant to the Veteran's claim as the Veteran clearly stated that his May 2002 stressor occurred during Operation Enduring Freedom rather than Operation Iraqi Freedom. The record shows that the AOJ made efforts to follow up with the Veterans Affairs Liaison Officer as recommended by the JSRRC in a series of e-mails dated from July 2018 through August 2018. The e-mails ultimately led to the liaison providing the response he received from the United States Air Force Historian to the AOJ in August 2018. The historian stated that after reviewing the 379th Air Expeditionary Wing and Central Command histories for May 2002, they were unable to verify the event described in the Veteran's statement. The liaison separately noted that due to the Veteran's report that the event happened on May 1, 2002, the Air Force Historians focused on the month of May. However, the record also includes a July 2019 buddy statement in which S.B. provided details that were largely similar to those noted in the Veteran's September 2014 stressor statement. S.B. noted that the Veteran was former member of the 127th Security Forces Squadron, and their unit deployed in support of Operation Enduring Freedom in February 2002 to Al Udeid Air Base in Qatar. S.B. recalled that this base was barren and in a classified location. S.B. stated that he could confirm that the events described by the Veteran at Al Udeid did happen, including a sniper incident that occurred at the gate one evening when the Veteran was stuck on the roof alone. S.B. reported that the Veteran was upset and distant after the sniper fire incident, and he conveyed to S.B. how scared he had been. S.B. also assumed that the Veteran was more on edge than everyone else as the Veteran's wife was expecting their daughter at that time. S.B. additionally reported that upon returning from Al Udeid, the Veteran began to withdraw from people; and S.B. observed him to always be on edge. To this day when they spent time together, the Veteran was hypervigilant such that he always wanted to watch the entry and exits at a restaurant, and he avoided crowded areas. In another July 2019 buddy statement, D.R. reported that he also deployed with the Veteran to Al Udeid Air Base in 2002 in support of Operation Enduring Freedom; and D.R. was able to recall similar details of the sniper fire incident that occurred at the main gate and involved the Veteran going to the roof with only a pistol and night vision goggles. Additional buddy statements from B.L., K.W., and A.P. in August 2019 also supported that the Veteran went to the roof in a position that was separated and alone during an incident where shots were fired at the main gate during their 2002 deployment to Al Udeid Air Base in Qatar. A VA examination related to the Veteran's claim was conducted in February 2016. The examiner noted that the Veteran reporting having two different in-service stressors. The first stressor included details largely consistent with those noted in the Veteran's September 2014 stressor statement. The examiner noted that the stressor occurred in April 2002 and involved encountering sniper fire at a gate where they were searching vehicles. The Veteran indicated that although he went on a roof to target a sniper, he could not see anyone. No one was hurt during this event. The examiner noted that this stressor met Criterion A (i.e., it was adequate to support the diagnosis of PTSD), and the stressor related to the Veteran's fear of hostile military or terrorist activity. The examination was also conducted by a psychologist. Thus, the Board finds that the criteria set forth in 38 C.F.R. § 3.304(f)(3) regarding confirmation from a VA psychologist or psychiatrist are met. In addition, the Board finds that this stressor is consistent with the places, types, and circumstances of the Veteran's service. The Veteran's military personnel records confirm that his active duty service included service at the Al Udeid Air Base in Qatar in 2002 during the period that the Veteran reported the stressor had occurred. In addition, the several buddy statements submitted on the Veteran's behalf supported that the details provided by the Veteran regarding this in-service stressor were accurate. Based on the foregoing, and resolving any doubt in favor of the Veteran, the Board finds that the Veteran's stressor has been established. The only remaining question is whether the Veteran has a current diagnosis of PTSD based on his established stressor. The February 2016 VA examiner found that the Veteran did not meet the diagnostic criteria for PTSD under the DSM-5 criteria. In addition, the examiner reported that the Veteran did not have any other mental disorder that conformed with the DSM-5 criteria. In light the examiner's finding that the Veteran did not meet the DSM-5 criteria for PTSD, the examiner provided a negative nexus opinion. The post-service treatment records also include a November 2015 VA treatment record that noted an assessment of positive PTSD and depression screens without noting a diagnosis for either disorder. In February 2017, E.B., PhD, licensed professional counselor (LPC), provided a positive opinion in support of the Veteran's claim. E.B. explained that he was a fully trained eye movement desensitization and reprocessing (EDMR) practitioner, and he provided services to servicemembers and others who had experienced severe trauma. The Veteran had been a patient under E.B.'s care since January 2017. E.B. stated that he had reviewed all statements of specific and general events occurring during service in addition to conducting a clinical assessment. E.B. noted that the relevant statements were attached to the letter, and the Board notes that the attachments included the Veteran's September 2014 stressor statement that provided details regarding his established stressor event involving the sniper fire in 2002. E.B. opined that these events were more likely, rather than less likely, to have caused the PTSD that the Veteran experiences. E.B. explained that the Veteran's patterns of behavior were in many ways characteristic symptoms of this disorder. E.B. pointed to several different behaviors in support of this conclusion, including the Veteran's diminished interest and participation in significant activities as well as his extreme vigilance while driving. E.B. also found it significant that all of these symptoms appeared after the Veteran's service. E.B. additionally explained that the Veteran's disturbances in social and occupational functioning were not attributable to any the physiological effects of a substance or another medical condition. Later in February 2020, E.B. completed a PTSD Disability Benefits Questionnaire (DBQ) and noted that the Veteran had a current diagnosis of PTSD. As the form included a prompt for the provider to indicate the Axis category, E.B. noted that it was an Axis I diagnosis. E.B. also stated that the Veteran did not have more than one mental disorder diagnosis. E.B. noted under the remarks section of the DBQ that the Veteran was very vigilant due to the attempted poisoning of his unit's water supply. However, E.B. did not provide any further opinion to suggest that the diagnosis was based on any one stressor other than those discussed in E.B.'s February 2017 opinion. The Board notes that as E.B.'s February 2017 and February 2020 findings that the Veteran had a PTSD diagnosis were provided after the May 2013 release of the DSM-5, the Board presumes that the diagnoses were made in accordance with the DSM-5 criteria. See Cohen v. Brown, 10 Vet. App. 128, 140 (1997). In March 2021, H.H., PhD, limited license psychologist (LLP), completed a Review PTSD DBQ. The form included instructions advising the provider that the evaluation should be based on the DSM-5 diagnostic criteria. H.H. noted that the Veteran had a current diagnosis of PTSD, chronic; and did not have a diagnosis for any other mental disorder. In a separate March 2021 opinion, H.H. indicated that she had reviewed the Veteran's STRs and past medical history in addition to conducting the psychological interview for the DBQ. H.H. noted that there was no indication that the Veteran had any psychological treatment or diagnoses prior to entering the military. H.H. opined that the Veteran suffered from PTSD due to his service in Operation Enduring Freedom, and H.H. indicated that she had reviewed the multiple buddy statements of record in reaching this conclusion. These buddy statements reflected that the Veteran experienced traumatic events during this deployment while serving in the Security Forces Squadron that caused him to fear for his life. H.H. highlighted the details provided by the different buddy statements, including the statements discussed above related to the Veteran's established stressor involving the sniper in 2002. H.H. stated that these traumatic events caused the Veteran to fear for his life, thereby causing his current PTSD. Therefore, H.H. opined that the Veteran's current PTSD was more likely than not a result of the traumatic events that occurred during his active duty service. The Board finds that the opinion from the February 2016 examiner that the Veteran did not meet the DSM-5 criteria for a PTSD diagnosis is probative as it was based on the examiner's evaluation of the Veteran and her medical expertise. However, the subsequent determinations from E.B. and H.H. in February 2017, February 2020, and March 2021 that the Veteran does have diagnosis of PTSD based on the DSM-5 criteria are also probative as they considered relevant clinical findings and the appropriate diagnostic criteria in reaching their determinations. As indicated above, the opinions from E.B. and H.H. also reflect that the Veteran's established stressor played a role in causing his current PTSD. The Board finds that the weight of evidence is persuasively in favor of finding that the Veteran has a current PTSD diagnosis under the DSM-5 that is at least partly related to his established stressor. Moreover, entitlement to service connection can be granted if the Veteran suffers from a disability at any point during the claims or appeals period. McClain v. Nicholson, 21 Vet. App. 319 (2007). Resolving all benefit of the doubt in favor of the Veteran, service connection for PTSD is warranted. 38 U.S.C. §§ 101, 1110; 38 C.F.R. §§ 3.6, 3.102, 3.303, 3.304(f), 4.125(a). The Board notes that to the extent that a January 2019 private treatment record noted that the Veteran's past medical history included anxiety, the benefit sought on appeal is granted in a manner consistent with the fact that the most probative evidence shows that the proper DSM-5 diagnosis for the Veteran's current psychiatric symptoms is PTSD. Entitlement to service connection for temporomandibular joint dislocation. The record has raised the theory that the Veteran has TMD that is secondary to his now service-connected PTSD disability. The Veteran's STRs do not show any complaint, diagnosis or treatment related to TMD. After service, a September 2013 VA treatment record noted an assessment of history of temporomandibular joint dysfunction (TMJ) without documenting an actual diagnosis for this disorder. In July 2014, R.K., a dentist, completed a Temporomandibular Joint Conditions DBQ in connection with the Veteran's claim. R.K. stated that the Veteran had a diagnosis for TMD. R.K. explained that the Veteran was in the early stages of TMD, and R.K. had made no diagnosis of TMJ. A subsequent November 2015 VA treatment record noted an assessment of history of TMD. A February 2017 VA treatment record later noted history of TMJ under the assessment without indicating that any current assessment of TMJ was made at that time. The Veteran indicated during the March 2021 Board hearing that he discovered he had TMD when he began to experience headaches and sought treatment from his dentist. The Veteran's dentist informed the Veteran that being stressed could lead to clenching of the jaw and grinding before informing the Veteran that he had TMD/TMJ. The Veteran also indicated that E.B. confirmed that PTSD and TMD were connected, and one could set off the other. The Board notes that the Veteran is competent to report events he experienced and information that a medical provider told him. See Layno v. Brown, 6 Vet. App. 465 (1994); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Board also finds the Veteran to be credible as the information appears to be consistent with the finding of TMD noted by the dentist R.K. in the July 2014 DBQ as well as the March 2021 medical opinion discussed below. In March 2021, Dr. M., MD, provided a positive opinion in support of the Veteran's claim. Dr. M. stated that he had reviewed the Veteran's service records and past medical history. Dr. M. noted that the Veteran suffered from temporomandibular joint dysfunction. Dr. M. added that according to medical literature from the Cleveland Clinic, stress, which can cause a person to tighten muscles in the face and jaw, or to clench teeth, is known to cause temporomandibular joint dysfunction. Dr. M. explained that the Veteran's PTSD likely caused him to tighten his face and jaw muscles and/or clench his teeth as this is a common symptom with stress. Therefore, Dr. M. opined that the Veteran's temporomandibular joint dysfunction is at least as likely as not secondary to his PTSD that was caused by his time in service. The Board finds that Dr. M.'s opinion is highly probative as Dr. M. indicated that he had a general understanding the Veteran's relevant medical history, and Dr. M. provided a complete rationale that included consideration of relevant medical literature. Although Dr. M. appeared to only discuss TMJ in the opinion, a review of the Cleveland Clinic article referenced by Dr. M. that was attached to the opinion supports the conclusion that Dr. M.'s reasoning also applies to the Veteran's diagnosed TMD. Rather than being limited to addressing TMJ, the article was entitled "Temporomandibular Disorders (TMD): Overview," and it discussed the causes of TMD, including stress as highlighted by Dr. M. There is also no negative opinion of record concerning this theory of entitlement to contradict Dr. M.'s conclusion. In light of the above discussion, the weight of the evidence supports finding that the Veteran's diagnosed TMD is due to, or the result of, his PTSD. Service connection for TMD is therefore granted as secondary to service-connected PTSD. 38 C.F.R. § 3.310. As the Board is granting entitlement to service connection on this basis, it is unnecessary to address any other theory of service connection that has been advanced. Entitlement to service connection for disorder manifested by right knee pain. The Veteran contends that he has a disorder manifested by right knee pain that is related to his active service. A review of the STRs shows that in a May 1985 Report of Medical History completed for a periodic service examination, the Veteran reported a history of a "trick" or locked knee. The corresponding May 1985 service examination stated under the notes section that the Veteran sustained a right knee injury while playing football at age 14. However, there was no sequalae, and no limitation in activity. The record added that the Veteran denied, and a review of medical records failed to reveal, any other significant medical or surgical history since the last examination. No defects were noted in the report. In this regard, the lower extremities were found to be normal on clinical evaluation. Next to this category, it was noted that the right knee had no effusion, no joint laxity, full range of motion, and good strength. Moreover, the Veteran's STRs are otherwise silent for any complaint, treatment, or diagnosis related to the right knee. As such, there is no suggestion of a preexisting right knee disorder from the STRs. The Veteran also confirmed during the March 2021 Board hearing that he did not receive a diagnosis for any chronic right knee disorder prior to his period of active duty. During the March 2021 Board hearing, the Veteran and his representative indicated that some of his symptoms of chronic right knee pain were present during his active duty service while he was overseas. The Veteran specifically confirmed that he first noticed having right knee pain that was more constant while he was deployed to Qatar. The representative explained that his right knee symptoms began during service, and it was the Veteran's contention that his active duty activities as part of the security forces led to his chronic knee pain. The Veteran reported that his in-service duties in this role required him to kneel, crawl, and lift heavy objects almost constantly. The Board notes that the Veteran is competent to report his history of observable symptoms such as right knee pain. Layno v. Brown, 6 Vet. App. 465 (1994); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board also finds the Veteran's reported history to be credible as the Veteran provided an explanation during the hearing for the lack of documentation of right knee complaints in the STRs. The Veteran explained that he felt discouraged from going to the clinic for treatment and perceived the expectation to be for him to "buck it up and press on." The Veteran added that some days his right knee would not hurt, but he would be limping along on other days. The Board also finds the Veteran's reported physical activities associated with his primary specialty of security police supervisor while on active duty in Qatar from March 2002 to June 2002 to be credible and consistent with the circumstances of his service. 38 U.S.C. § 1154(a). In March 2014, S.R., DO, completed a DBQ related to the right knee. S.R. noted that the Veteran had a diagnosis for right knee pain and indicated that it dated to approximately 2003. S.R. noted under the medical history that the Veteran engaged in repetitive up and down motions in service that caused severe wear and tear on his right knee. The Veteran reported that he had flare ups impacted the function of his right knee when squatting or bending. S.R. also found that the Veteran had functional loss in the form of less movement than normal. Although arthritis was not documented in the diagnosis section of the report, S.R. reported under the diagnostic testing section of the DBQ that available imaging studies of the knee documented right knee degenerative or traumatic arthritis. Under the functional impact section of the report, S.R. also indicated that the Veteran's right knee pain impacted his ability to work as he had difficulty standing or bending for long periods of time. In light of S.R.'s findings from the diagnostic testing portion of the DBQ, the Board concludes that S.R. found the Veteran to have right knee arthritis in addition to the diagnosis of right knee pain that was noted in the diagnosis section of the DBQ. Later in February 2019, a private treatment record stated that the Veteran fell on the ice that morning exiting his truck, and he now had a painful left elbow, painful to the touch symptoms at the middle of his back, and soreness at the right knee. The physical examination showed mild ecchymosis to the right knee. The impression was elbow pain and falling injury. In addition to providing an opinion that addressed the Veteran's diagnosed TMD, Dr. M. provided a March 2021 opinion related to the Veteran's service connection claim for a right knee disorder. Dr. M. reported that he had reviewed the Veteran's service records and past medical history, and Dr. M. noted that the Veteran currently suffered from right knee pain. Dr. M. also observed that the Veteran's DD 214 showed that he served as Security Police Supervisor while in service. Dr. M. stated that according to information from the Air Force, his job duties included controlling and securing the terrain inside and adjacent to military installations, as well as the military personnel, equipment, and resources within. The Veteran was required to maintain a high level of physical preparedness, and he performed highly physical job duties. The Board notes that Dr. M. attached an internet article from the Air Force's website that discussed the duties of a security force officers in support of this opinion. Dr. M. noted that according to medical literature from Healthline, physical exercise is a risk factor for chronic knee pain. Dr. M. stated that as the Veteran performed physical job duties and rigorously trained to maintain combat readiness, it is likely that these activities caused him to develop his current chronic right knee pain. Therefore, Dr. M. opined that the Veteran's chronic right knee pain is at least as likely as not due to his active duty service. Although Dr. M.'s opinion did not specifically reference the arthritis noted in the March 2014 DBQ, the DBQ indicates that this diagnosis is associated with the Veteran's right knee pain. This conclusion is also consistent with an August 2019 internet article related to chronic right knee pain that was attached to Dr. M.'s opinion which stated that the physical conditions or diseases that can cause knee pain include osteoarthritis. As such, the Board finds that Dr. M.'s opinion contemplated the Veteran's right knee pain as well as his arthritis. The Board finds that this opinion provides great probative value as Dr. M. considered the Veteran's relevant medical history and included a thorough rationale that was supported by several pertinent articles. Dr. M.'s opinion is also consistent with S.R.'s statement from the March 2014 DBQ indicating that the Veteran's in-service physical activities caused severe wear and tear on his right knee. Notably, there is no negative medical opinion to weigh against Dr. M.'s conclusion. Although the Board has also considered the February 2019 private treatment record's report that the Veteran had right knee soreness following a falling injury, the March 2014 DBQ shows that the Veteran's right knee pain and arthritis preceded this injury. (CONTINUED ON NEXT PAGE) Based on the foregoing, the Board finds that the evidence weighs persuasively in favor of finding that the Veteran's disorder manifested by right knee pain, diagnosed as arthritis, is related to his active duty service. Entitlement to service connection is therefore granted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. GAYLE STROMMEN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K.C. Spragins, 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. .