Back to BVA DecisionsDENIEDSpecial Benefit NO SPECIAL BENEFIT Docket No. 200506-82324
HYPERTENSION
DONNIE R. HACHEY · 2022 · Case ID: A22004102
Summary
The veteran, who served on active duty from January 2012 to January 2016, appeals the denial of service connection for a heart condition, a back disorder, and a right hip disorder. The veteran claimed the heart condition began during service and was misdiagnosed, and that the back and hip disorders were either due to repetitive stress during service or secondary to other service-connected conditions (left ankle Achilles tendinosis for the back, and right knee patellar tendinosis for the hip). The Board denied all claims. For the heart condition, the Board found no evidence of a current heart disorder, noting that while service records showed a small amount of pericardial fluid after childbirth, there were no concerning findings or follow-up, and no subsequent complaints or objective signs of cardiovascular abnormalities. The Board also found no evidence of a 2019 arrhythmia diagnosis. For the back disorder, the Board found no current back disorder, noting a childhood history of spina bifida occulta but no ongoing symptoms or loss of function. Service treatment records were silent on back complaints, and a VA examination showed full, painless range of motion with no objective abnormalities. For the right hip disorder, the Board found no current hip disability, noting service records were silent on hip complaints or abnormalities, and post-service treatment records showed no hip complaints or treatment. A bilateral hip examination showed full, painless right hip motion with no pathology. The Board concluded that the evidence did not trigger the duty to assist in obtaining further examinations for any of the claimed conditions due to the lack of evidence suggesting a current disorder.
Rationale
No evidence of current heart disorder; Service records silent on cardiac abnormalities; No evidence of 2019 arrhythmia diagnosis
Full Decision Text
Citation Nr: A22004102 Decision Date: 03/09/22 Archive Date: 03/09/22 DOCKET NO. 200506-82324 DATE: March 9, 2022 ORDER Entitlement to service connection for a heart condition is denied. Entitlement to service connection for a back disorder, to include as secondary to left ankle Achilles tendinosis, is denied. Entitlement to service connection for a right hip disorder, to include as secondary to right knee patellar tendinosis, is denied. FINDINGS OF FACT 1. The Veteran does not have a heart disorder that is related etiologically to her active duty service or service-connected disabilities. 2. The Veteran does not have a back disorder that is related etiologically to her active duty service or service-connected disabilities. 3. The Veteran does not have a right hip disorder that is related etiologically to her active duty service or service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for service connection for a heart condition are not met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.307, 3.309(a) (2021). 2. The criteria for service connection for a back disorder are not met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.307, 3.309(a), 3.310 (2021). 3. The criteria for service connection for a right hip disorder are not met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.307, 3.309(a), 3.310 (2021). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 2012 through January 2016. The issues on appeal arise from the Veteran's March 2019 claim and the agency of original jurisdiction's (AOJ's) May 2019 rating decision. The Veteran has perfected a timely appeal of the May 2019 rating decision. After the Veteran was issued a December 2019 Statement of the Case (SOC), she filed a May 2020 VA Form 10182 in which she requested that this appeal be placed on the Board's Direct Review docket. The Board's review of this matter is limited to the evidence that was available to the AOJ at the time that the December 2019 SOC was issued. 1. Entitlement to service connection for a heart condition. The Veteran contends in her February 2020 substantive appeal that she received a diagnosis for cardiac arrhythmia in September 2019. She asserts that she had the onset of arrhythmia during her period of active duty service and that her condition was incorrectly diagnosed and treated during service as dehydration. The AOJ denied the Veteran's claim in the May 2019 rating decision on the basis that the evidence showed no current heart condition. The AOJ made no specific findings of fact. The AOJ continued to deny the Veteran's claim in the December 2019 SOC on the same basis and rationale. Again, the AOJ made no specific findings of fact. Upon review of the evidence, the preponderance of the evidence shows that the Veteran does not have a heart disorder. Accordingly, the Board concludes that the Veteran is not entitled to service connection for a heart disorder. Service treatment records from Camp Pendleton Naval Hospital show that in February 2015 the Veteran reported the sudden onset of chest pain 30 minutes after childbirth. A chest CT taken at that time showed a small amount of pericardial fluid but an otherwise normal heart study. Fluid was observed around the pancreas and abdomen with moderate bilateral hydronephrosis secondary to pregnancy. Still, there is no indication in the CT study that the Veteran had a specific heart condition or signs that were concerning for one and that warranted further cardiovascular follow-up. Indeed, the extensive subsequent service treatment records document no subjective complaints of a heart-related nature, nor do they indicate any objective signs of cardiovascular abnormalities during service. Records related to post-service VA treatment received by the Veteran through 2019 reflect that repeated physical examinations have shown no signs of a cardiovascular disorder. Contrary to the Veteran's claim that she received a diagnosis for arrhythmia in 2019, the records show that she has not reported any cardiovascular symptoms to her attending medical staff, and indeed, there is no indication in the records that rosis secondary to pregnancy. Still, there is no indication in the CT study that the Veteran had a specific heart condition or signs that were concerning for one and that warranted further cardiovascular follow-up. Indeed, the extensive subsequent service treatment records document no subjective complaints of a heart-related nature, nor do they indicate any objective signs of cardiovascular abnormalities during service. Records related to post-service VA treatment received by the Veteran through 2019 reflect that repeated physical examinations have shown no signs of a cardiovascular disorder. Contrary to the Veteran's claim that she received a diagnosis for arrhythmia in 2019, the records show that she has not reported any cardiovascular symptoms to her attending medical staff, and indeed, there is no indication in the records that her attending medical staff has noted any objective cardiovascular signs or findings such as to warrant any medical workup, much less, a specific diagnosis for arrhythmia or other heart-related conditions. Notably, the Veteran is unable to direct VA's attention to a specific doctor or medical provider who rendered the purported 2019 arrhythmia diagnosis and there is no evidence in the record showing such a diagnosis. To the extent that the Veteran may be construed as asserting that she has a current condition that may be related to her episode of chest pain shortly after giving childbirth in February 2015, she is not competent to provide an opinion as to the existence of such an etiological relationship even if the current record did show that she has a current disorder. The Board need not reach that analysis, however; the absence of evidence showing that the Veteran has a current heart disorder is fatal to her claim. The Board is aware that the Veteran did not undergo a heart examination during the development of her claim. Nonetheless, in the absence of any competent and/or probative evidence even suggesting that the Veteran has a current heart condition, the relatively low evidentiary standard for triggering VA's pre-decisional duty to assist in affording the Veteran such an examination still is not met. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 84 (2006). The preponderance of the evidence shows that the Veteran does not have a heart disorder. The Veteran is therefore not entitled to service connection for a heart condition. 2. Entitlement to service connection for a back disorder. The Veteran asserts that she has daily back pain which she believes resulted from repetitive physical stress and strain during her active duty service. To that end, she describes various in-service activities that include participating in weighted hikes and marches, frequently carrying radio equipment and other gear on her back, and heavy lifting and carrying while loading ships for deployment. Alternatively, the Veteran also theorizes in her May 2019 claim that her current back problems are secondary to her service-connected left ankle disability. The Veteran's claim for service connection for a back disorder was denied in the AOJ's May 2019 rating decision. As basis, the AOJ determined that the evidence showed no current back disorder, to include pain. No specific findings of fact were noted. The AOJ continued its denial on the same rationale and basis in the December 2019 SOC. Again, the AOJ made no specific findings of fact. Upon review of the evidence, the preponderance of the evidence shows that the Veteran does not have a current back disorder. Accordingly, the Board concludes that the Veteran is not entitled to service connection for a back disorder. Notably, the Veteran's service treatment records include an October 2014 note which reflects that the Veteran reported a childhood history of spina bifida occulta. According to the Veteran, she "grew out of" the condition. Although she reported a history of scoliosis that resulted from her spina bifida occulta, she denied having any ongoing symptoms or loss of function related to her spine. Indeed, subsequent service treatment records reflect no subjective back-related complaints from the Veteran, nor do they reflect any objective findings of any spine-related abnormalities or concerns such as to warrant further spine-related workup or treatment. Similarly, records for post-service VA treatment received by the Veteran through 2019 note no subjective complaints from the Veteran. Moreover, repeated physical, musculoskeletal, and neurological examinations of the Veteran have shown no evidence of any abnormalities. Based on the Veteran's complaints of back pain with apparent onset shortly after her separation from service, the Veteran was afforded a spine examination in April 2019. Although the Veteran continued to report back pain during the examination, a physical spine examination showed that the Veteran had full and painless thoracolumbar spine motion. No pain or tenderness was reported by the Veteran or observed by the examiner during palpation and weight bearing. No evidence of guarding or spasms were observed. Overall, the examination showed for post-service VA treatment received by the Veteran through 2019 note no subjective complaints from the Veteran. Moreover, repeated physical, musculoskeletal, and neurological examinations of the Veteran have shown no evidence of any abnormalities. Based on the Veteran's complaints of back pain with apparent onset shortly after her separation from service, the Veteran was afforded a spine examination in April 2019. Although the Veteran continued to report back pain during the examination, a physical spine examination showed that the Veteran had full and painless thoracolumbar spine motion. No pain or tenderness was reported by the Veteran or observed by the examiner during palpation and weight bearing. No evidence of guarding or spasms were observed. Overall, the examination showed no abnormalities, to include pain. Based on the findings from the examination, the examiner concluded that the Veteran has no pathology for a back disorder. The examiner's findings and conclusions are not rebutted by other medical evidence in the record. The preponderance of the evidence shows that the Veteran does not have a back disability. The Veteran is therefore not entitled to service connection for a back disorder, to include as secondary to left ankle Achilles tendinosis. 3. Entitlement to service connection for a right hip disorder, to include as secondary to right knee patellar tendinosis. The Veteran asserts in her May 2019 claim and February 2020 VA Form 9 substantive appeal that she experiences daily right hip pain that she believes resulted from repetitive physical stress during service and/or her service-connected left knee disability. The AOJ denied the Veteran's claim in the May 2019 rating decision on the basis that the evidence showed that the Veteran did not have a current right hip disability. That denial was continued in the AOJ's December 2019 SOC. No specific findings of fact were identified. The Board agrees that the Veteran does not have a current right hip disability. As such, the Board concludes that the Veteran is not entitled to service connection for a right hip disability. The Veteran's service treatment records are completely silent for any right hip-related complaints by the Veteran, nor do they reflect any objectively observed right hip abnormalities such as to warrant further study, treatment, or workup of the Veteran's hip. In sum, there is no evidence of an in-service injury or event involving the Veteran's right hip, and indeed, the Veteran does not seem to contend that any such in-service event occurred. In support of her claim, the Veteran states in her May 2020 VA Form 10182 that she has been receiving VA treatment for her hip problems for five years (since 2015). The post-service VA treatment records, however, reflect no such treatment. Indeed, records for VA treatment received by the Veteran from 2016 through 2019 indicate no subjective complaints by the Veteran for any hip-related complaints. Moreover, repeated physical and musculoskeletal examination showed no hip-related abnormalities. Contrary to the Veteran's assertions that she has received ongoing treatment for a right hip disorder, there is no information or evidence in the records showing that the Veteran has been under any treatment for a right hip disorder. In conjunction with the foregoing, the Veteran was afforded a bilateral hip and lower extremity examination in July 2016 as part of development of a claim for service connection for a left hip disorder. That examination showed that the Veteran had full and painless right hip motion with no evidence of local pain or tenderness over the hip joint. Strength in the right hip was full and there was no evidence of any functional impairment in the joint. The examiner apparently noted no right hip pathology and declined to render a right hip diagnosis given the absence of any pathology. The Board notes that the Veteran has not received an examination specific to her right hip as part of the development of this appeal. Under similar analysis as that undertaken by the Board in relation to the heart issue, VA's pre-decisional duty to assist in affording the Veteran such an examination still is not triggered given the absence of any evidence which suggests a current hip disorder. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 84 (2006). The preponderance of the evidence shows that the Veteran does not have a right hip disability. The Veteran is not entitled to service connection for a right hip disorder, to include as secondary to right knee patellar tendinosis. DONNIE R. HACHEY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D.S. Lee 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 (c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 84 (2006). The preponderance of the evidence shows that the Veteran does not have a right hip disability. The Veteran is not entitled to service connection for a right hip disorder, to include as secondary to right knee patellar tendinosis. DONNIE R. HACHEY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D.S. Lee 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.