MIGRAINE

C.B. IWANOWSKI · 2026 · Case ID: A26003861

MIXED

Summary

The Veteran, an Army Veteran who served from July 2006 to January 2008, appeals the denial of service connection for tension headaches, GERD, and a left shoulder disability, and the remand of his cervical spine disability claim. The Veteran contends that his tension headaches and GERD are secondary to his service-connected PTSD. For tension headaches, the Board found the VA opinions inadequate, noting they failed to address the Veteran's lay statements and the link between PTSD and headaches. A private physician opined a positive nexus between the headaches and PTSD. For GERD, the Board found the VA opinions inadequate, particularly regarding the role of obesity and PTSD. A private physician opined a positive nexus between GERD and PTSD, citing medical literature. For the left shoulder disability, the Board found the VA opinion inadequate for relying solely on the absence of service treatment records, failing to consider lay statements about in-service injury and arduous duties as an armor crewman. A private physician provided a positive nexus opinion linking the shoulder disability to his MOS. The Board granted service connection for tension headaches, GERD, and the left shoulder disability, resolving reasonable doubt in the Veteran's favor. The cervical spine claim was remanded due to a pre-decisional duty to assist error, as the VA examiner inadequately addressed the Veteran's lay statements and the private opinion regarding the onset of neck pain.

Rationale

VA opinions inadequate for failing to address lay statements and link between PTSD and headaches.; Private medical opinion provided a competent positive nexus between headaches and PTSD.; Reasonable doubt resolved in Veteran's favor.

Service Branch

ARMY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

241004-478213

Full Decision Text

Citation Nr: A26003861
Decision Date: 01/15/26 Archive Date: 01/15/26

DOCKET NO. 241004-478213
DATE: January 15, 2026

ORDER

Service connection for tension headaches is granted.

Service connection for gastroesophageal reflux disease (GERD) is granted.

Service connection for left shoulder myofascial pain syndrome (left shoulder disability) is granted.

REMANDED

Entitlement to service connection for cervical spine intervertebral disc syndrome (cervical spine disability) is remanded.

FINDINGS OF FACT

1. The Veteran has a current diagnosis of tension headaches; it is at least as likely as not that the disability can be attributed to his service-connected posttraumatic stress disorder (PTSD).

2. The Veteran has a current diagnosis of GERD; it is at least as likely as not that the disability can be attributed to his service-connected PTSD, or medications taken for that service-connected condition.

3. It is at least as likely as not that the Veteran has a left shoulder disability that is etiologically related to service.

CONCLUSIONS OF LAW

1. Resolving reasonable doubt in the Veteran's favor, the criteria for an award of service connection for tension headaches have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

2. Resolving reasonable doubt in the Veteran's favor, the criteria for an award of service connection for GERD have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

3. Resolving reasonable doubt in the Veteran's favor, the criteria for an award of service connection for a left shoulder disability have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran had service in the United States Army from July 2006 to January 2008. His decorations include the National Defense Service Medal, Global War on Terrorism Service Medal, and Army Service Ribbon.

These matters come to the Board of Veterans' Appeals (Board) on appeal from a September 2024 rating decision issued by a Department of Veterans Affairs (VA) Regional Office. The Veteran timely appealed to the Board by filing a VA Form 10182 (Decision Review Request: Board Appeal (Notice of Disagreement)) in October 2024, requesting direct review of the evidence considered by the agency of original jurisdiction (AOJ). 38 C.F.R. §§ 20.201, 20.202(b)(1).

The Board notes that the Veteran specified in his October 2024 VA Form 10182 that it was a September 2023 decision that he wished to appeal. However, there is no such decision of record. The only decision of record which denied the claims on appeal within one year of the October 2024 VA Form 10182 is the September 2024 rating decision. Accordingly, the Board has construed the VA Form 10182 as an appeal of the September 2024 rating decision. See, e.g., Terry v. McDonough, 37 Vet. App. 1 (2023).

Under the direct review option, the Board may only consider the evidence of record at the time of issuance of the AOJ rating decision on appeal. 38 C.F.R. § 20.301. The Board cannot consider evidence submitted after that decision was promulgated.

By way of background, in December 2022, the Veteran filed a claim for a left shoulder condition, a right shoulder condition, a cervical spine condition, GERD and headaches. A February 2023 rating decision denied service connection for GERD, tension headaches, cervical spine - intervertebral disc syndrome and left shoulder and right shoulder myofascial pain syndrome of trapezius and thromboid musculature. The Veteran filed a request for higher level of review of that decision in February 2024. A February 2024 rating decision denied service connection for cervical spine and right and left shoulder disabilities and deferred consideration of GERD and headaches for further development. In a March 2024 rating decision, the AOJ confirmed and continued the prior denials. In August 2024, the Veteran filed a Supplemental Claim again seeking service connection for a cervical spine condition, headaches, right and left shoulder conditions, and GERD. In the September 2024 rating
cervical spine - intervertebral disc syndrome and left shoulder and right shoulder myofascial pain syndrome of trapezius and thromboid musculature. The Veteran filed a request for higher level of review of that decision in February 2024. A February 2024 rating decision denied service connection for cervical spine and right and left shoulder disabilities and deferred consideration of GERD and headaches for further development. In a March 2024 rating decision, the AOJ confirmed and continued the prior denials. In August 2024, the Veteran filed a Supplemental Claim again seeking service connection for a cervical spine condition, headaches, right and left shoulder conditions, and GERD. In the September 2024 rating decision on appeal, the AOJ found that new and relevant evidence had been presented or secured to warrant readjudication of the claims for tension headaches, GERD, the left shoulder and the cervical spine. The Board is bound by those favorable findings. 38 C.F.R. §§ 3.104(c), 20.801(a).

Notably, the AOJ did not address the right shoulder in the September 2024 rating decision, and the issue was not listed in the October 2024 VA Form 10182. The right shoulder was addressed in a March 2025 rating decision. The Veteran appealed the March 2025 decision in an August 2025 VA Form 10182. That appeal was docketed at the Board in September 2025, and the issue of entitlement to service connection for a right shoulder condition will be addressed in a separate Board decision.

As to the claim of entitlement to service connection for a neck disability, for the reasons set forth below, the Board is remanding the Veteran's claim to the AOJ for correction of a pre-decisional duty to assist error. The AOJ will consider any additional evidence that has been submitted when the claim is readjudicated. 38 C.F.R. § 3.103(c)(2)(ii).

Service Connection: Applicable Laws

Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999).

If a Veteran serves 90 days or more of active, continuous service after December 31, 1946, and manifests certain chronic diseases-to include arthritis and organic diseases of the nervous system-to a degree of 10 percent or more during the one-year period following his separation from that service, service connection for the condition may be established on a presumptive basis, notwithstanding that there is no in-service record of the disorder. See 38 U.S.C. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309.

Service connection may also be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307(i) and (ii) subsequent manifestations of the same chronic disease, or (b) if the fact of chronicity in service is not adequately supported, by evidence of continuity of symptomatology. However, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that the provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology can be applied only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).

On August 10, 2022, the President signed into law the Sergeant First Class Heath Robinson Honoring Our Promise to Address Comprehensive Toxics (PACT) Act of 2022, Pub. L. 117-168, 136 Stat. 1759 (2022). GERD, headaches, IVDS, and myofascial pain syndrome are not presumptive conditions under the PACT Act. However, the PACT Act led to the promulgation of 38 U.S.C. § 1168, which generally requires VA to provide a medical examination and opinion to any veteran with confirmed in-service toxic exposure and a current disability.

Under applicable law, disability which is
. 2013).

Under applicable law, disability which is due to, or the result of, a service-connected disease or injury shall also be service connected. 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 or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995).

Aggravation for purposes of 38 C.F.R. § 3.310(b) requires "any incremental increase in disability-any additional impairment of earning capacity-in nonservice-connected disabilities resulting from service-connected conditions, above the degree of disability existing before the increase-regardless of its permanence." Ward v. Wilkie, 31 Vet. App. 233, 239 (2019).

In Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023), the Federal Circuit held that 38 U.S.C. § 1110 employs only "but-for" (rather than proximate) causation in direct and secondary service connection claims. In that regard, the Federal Circuit held that 38 C.F.R. § 3.310(b) is unlawful because it requires proximate causation to establish aggravation of a disability, rather than but-for causation. The but-for causation standard is not limited to a single cause and effect, but rather contemplates multi-causal links, including action and inaction. The Federal Circuit explained that secondary service connection is warranted where a non-service-connected disability would have been less severe but-for a service-connected disability, either because there is an etiological link (to include worsening of functionality) between the two, or because the service-connected disability resulted in the inability to treat the non-service-connected disability. Stated another way, but-for causation is broad and undisputedly broader than proximate cause. Thus, a service-connected disability need only be a contributing cause, not the contributing cause, to establish secondary service connection.

Obesity can act as an "intermediate step" to establish service connection for one disability as secondary to an already service-connected disability under certain circumstances. See VAOPGCPREC 1-2017. VA General Counsel has indicated that establishing service connection in a case such as the Veteran's requires resolution of three issues: (1) whether a service-connected disability caused the Veteran to become obese; (2) if so, whether the obesity due to a service-connected disability was a substantial factor in causing the claimed disability; and (3) whether the claimed disability would not have occurred but for obesity caused by a service-connected disability. Id.

The United States Court of Appeals for Veterans Claims (Court) modified the analysis set out in the General Counsel's opinion, holding that in considering whether obesity is an "intermediate step," consideration must be given to whether obesity was caused or aggravated by a service-connected disability, consistent with 38 C.F.R. § 3.310. Walsh v. Wilkie, 32 Vet. App. 300 (2020).

In Garner v. Tran, 33 Vet. App. 241 (2021), the Court held that to reasonably raise a theory of secondary service connection via obesity as an intermediate step, there must be some evidence in the record which draws an association or suggests a relationship between the veteran's obesity, or weight gain resulting in obesity, and a service-connected condition.

A layperson is generally incapable of opining on matters requiring medical knowledge. However, lay evidence can be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (e.g., a broken leg, separated shoulder, pes planus (flat feet), varicose veins, tinnitus (ringing in the ears), etc.), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by
an intermediate step, there must be some evidence in the record which draws an association or suggests a relationship between the veteran's obesity, or weight gain resulting in obesity, and a service-connected condition.

A layperson is generally incapable of opining on matters requiring medical knowledge. However, lay evidence can be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (e.g., a broken leg, separated shoulder, pes planus (flat feet), varicose veins, tinnitus (ringing in the ears), etc.), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007).

In essence, lay testimony is competent when it pertains to the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also 38 C.F.R. § 3.159(a)(2). A determination as to whether medical evidence is needed to demonstrate that a Veteran presently has the same condition he or she had in service or during a presumptive period, or whether lay evidence will suffice, depends on the nature of the Veteran's present condition (e.g., whether the Veteran's present condition is of a type that requires medical expertise to identify it as the same condition as that in service or during a presumption period, or whether it can be so identified by lay observation). See Barr v. Nicholson, 21 Vet. App. 303, 310 (2007).

Thus, medical evidence is not always or categorically required when the determinative issue involves either medical diagnosis or etiology, but rather such issue may, depending on the facts of the particular case, be established by competent and credible lay evidence under 38 U.S.C. § 1154(a). See Davidson, supra.

When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. An approximate balance of the evidence includes, but is not limited to, equipoise. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). Evidence is not in "approximate balance" or "nearly equal" when the evidence persuasively favors one side or the other. Id.

In the September 2024 rating decision on appeal, the AOJ made favorable findings that the Veteran had been diagnosed with tension headaches, GERD, and cervical spine and left shoulder disabilities. The AOJ also found that participation in a toxic exposure risk activity (TERA) is conceded. Based on the Veteran's military operational specialty (MOS) of armor crewman, exposure to exhaust, excessive vibration, noise, solvent, vapors, dust, low level blast, extreme temperatures, lead, ionizing and non-ionizing radiation, radio frequency are conceded. Those favorable findings are binding on the Board and are not in dispute. 38 C.F.R. § 3.104(c). The Board also notes that the Veteran is service-connected for PTSD.

1. Service connection for tension headaches is granted.

The Veteran seeks to establish service connection for tension headaches. He contends that the disability is secondary to his service-connected PTSD.

On January 2023 VA headaches examination, the examiner diagnosed tension headaches. The Veteran indicated that headaches began in 2007. In a February 2023 medical opinion, the VA examiner opined that it is less likely than not that the Veteran's chronic tension headaches are proximately due to or the result of an acquired psychiatric disorder, other than PTSD. In the rationale the examiner explained that PTSD and other psychiatric illnesses are often comorbid with chronic migraine and chronic tension-type headaches. However, an association does not imply causation. The examiner stated, "There is no conclusive data or research to demonstrate an etiopathogenic relationship between PTSD/other psychiatric illnesses and the development of chronic tension headaches." The examiner also stated, "While the exact cause of [tension-type headaches] is not fully understood, there are links to various factors, including nutritional, muscular, environmental, and genetics."

In March 2024, a second VA examiner opined that the Veteran's claimed tension headaches are less likely than not caused by the indicated toxic exposure risk activity(ies), after considering the total potential exposure through all
explained that PTSD and other psychiatric illnesses are often comorbid with chronic migraine and chronic tension-type headaches. However, an association does not imply causation. The examiner stated, "There is no conclusive data or research to demonstrate an etiopathogenic relationship between PTSD/other psychiatric illnesses and the development of chronic tension headaches." The examiner also stated, "While the exact cause of [tension-type headaches] is not fully understood, there are links to various factors, including nutritional, muscular, environmental, and genetics."

In March 2024, a second VA examiner opined that the Veteran's claimed tension headaches are less likely than not caused by the indicated toxic exposure risk activity(ies), after considering the total potential exposure through all applicable military deployments of the veteran and the synergistic, combined effect of all toxic exposure risk activities of the Veteran. In the rationale, the examiner stated that with his MOS of armor crewman the Veteran was exposed to exhaust, vibration and noise, solvents, vapors, dust, low level blast, extreme temperatures, lead, ionizing and non-ionizing radiation, and radiofrequency during service. He stated that, "there is no significant evidence that suggests a relationship between the development of tension headache from exposure to TERA. Information provided by VA does not identify tension headaches as a presumptive condition occurring from exposure." He cited an article from the Cleveland Clinic which states that the cause of tension-type headaches is not known, but that anxiety and depression are identified as factors that can cause tension-type headaches. The examiner stated that a review of the records shows that the Veteran has mental health conditions and degenerative arthritis of the neck "which are factors identified by cited resource, which are probable reasons for the development of the claimed tension headache."

The physician stated that the Veteran suffered from chronic headaches and noted his history of service as a mortarman. He opined that the Veteran's chronic headaches are at least as likely as not due to his service-connected PTSD. He stated, "The association between PTSD and the development of chronic headaches is widely accepted in contemporary medicine. The relationship between PTSD and chronic headaches is well-documented in today's medical literature. In addition, peripheral adrenergic hypersensitivity and clinical symptomatology related to sympathetic nervous system dysfunction (e.g., orthostatic symptoms and pupillary differences) have been described in individuals diagnosed with chronic headaches."

On review, the Board is satisfied that the requirements for an award of secondary service connection have been satisfied. The January 2023 VA examination is inadequate for adjudication as it does not comply with Spicer, discussed supra. Taken together, the March 2024 and private medical opinion provide a competent positive nexus between the Veteran headaches and his PTSD or PTSD symptoms. Given this, the evidence, at a minimum, gives rise to a reasonable doubt on the matter. 38 C.F.R. § 3.102. Therefore, the appeal of this issue is granted.

2. Service connection for GERD is granted.

The Veteran seeks to establish service connection for GERD. He contends that the disability is secondary to his service-connected PTSD.

In a December 2022 Statement in Support of Claim, the Veteran indicated that due to his service-connected mental health condition he was less motivated to exercise and that had caused him to gain weight. He explained that he gained 35 pounds during service and an additional 8 pounds since then. He explained that his symptoms of heartburn with acid reflux and upper abdominal pain occurred daily and were worse when he was feeling anxious or stressed.

On January 2023 VA esophageal conditions examination, the examiner diagnosed GERD. The Veteran indicated that his condition began in 2008 due to "speed eating" and that he experienced heartburn and acid reflux when the condition began. He indicated treatment with over-the-counter medications to include Tums and Prilosec.

In February 2023, the VA examiner opined that the claimed GERD is less likely than not proximately due to or the result of the Veteran's acquired psychiatric disorder, other than PTSD. She stated that the factors influencing GERD are both physiologic and pathologic, such as obesity, diet, and medications. She explained that: "To date a few studies describing GERD have shown that psychological factors, particularly anxiety and depression, play an important role in patients with GERD; however, the results of those studies have been inconsistent. While there is evidence that psychological conditions can exacerbate GERD symptoms, no etiopathogenic relationship has been identified between psychological conditions and the development of GERD."

In March 2024,
2023, the VA examiner opined that the claimed GERD is less likely than not proximately due to or the result of the Veteran's acquired psychiatric disorder, other than PTSD. She stated that the factors influencing GERD are both physiologic and pathologic, such as obesity, diet, and medications. She explained that: "To date a few studies describing GERD have shown that psychological factors, particularly anxiety and depression, play an important role in patients with GERD; however, the results of those studies have been inconsistent. While there is evidence that psychological conditions can exacerbate GERD symptoms, no etiopathogenic relationship has been identified between psychological conditions and the development of GERD."

In March 2024, a VA examiner opined that the while obesity can be the intermediate step in mood disorders, the Veteran's GERD was less likely than not proximately due to or the result of his service-connected PTSD. In the rationale, the examiner stated that he could not directly state that the Veteran had obesity solely due to PTSD. He also had another risk factor of alcohol use disorder which contributed to obesity.

In a March 2024 addendum, the examiner opined that GERD is a common diagnosis and obesity does not directly cause GERD. He explained that the Veteran would likely have developed GERD as he does not have significant obesity as seen through his BMI on multiple exams. Therefore, the Veteran's obesity is less likely than not proximately due to or the result of PTSD and is not causing or exacerbating the GERD diagnosis.

The March 2024 VA examiner also opined that the Veteran's claimed GERD is less likely than not caused by the indicated toxic exposure risk activity(ies), after considering the total potential exposure through all applicable military deployments of the veteran and the synergistic, combined effect of all toxic exposure risk activities of the Veteran. The rationale was that GERD is not caused by the toxic exposures experienced by this claimant (exhaust, excessive vibration and nose, solvent, vapors, dust, low level blast, extreme temperatures, lead, ionizing and non-ionizing radiation, radio frequency). The examiner stated that GERD is a common diagnosis.

In an April 2024 private medical opinion Dr. N.P.D. indicated that he reviewed the entire file, including but not limited to military medical records, private medical records, VA medical records, and VA examinations. The physician stated that the Veteran first experienced symptoms of GERD in 2008. He stated that the relationship between PTSD and the development of GERD is well-documented in medical literature. The physician stated, "The phenomenon lies in the fact that GERD can develop when the symptoms of PTSD, such as anxiety, stress, and depression, lead to an overproduction of stomach acid." Therefore, in the Veteran's case his diagnosis of GERD "is at least as likely as not due to his service-connected post-traumatic stress disorder."

On review, the Board is satisfied that the requirements for an award of secondary service connection have been satisfied. The evidence, at a minimum, gives rise to a reasonable doubt on the matter. 38 C.F.R. § 3.102. The appeal of this issue is granted.

3. Service connection for a left shoulder disability is granted.

The Veteran seeks to establish service connection for a left shoulder disability.

Turning to the evidence, the service treatment records are void of any findings, complaints, symptoms, or diagnosis related to any left shoulder disability.

VA treatment records includes a May 2017 which includes a complaint of neck pain that radiated to the Veteran's shoulders.

In a December 2022 Statement in Support of Claim, the Veteran indicated he injured both shoulders while on active duty from physical training exercises and carrying an overweight rucksack. He stated he has had issues with his shoulders ever since active duty, to include pain, limited movement, muscle fatigue, cracking and popping. He reported self-treatment, to include taking Advil, Aleve, Ibuprofen, Tylenol and Icy Hot topically.

On January 2023 VA shoulder and arm conditions examination the examiner diagnosed myofascial pain syndrome of trapezius and rhomboid musculature. The Veteran stated that his symptoms began in 2007 due to constantly carrying overweight items.

In a February 2023 medical opinion the VA examiner opined that the claimed left shoulder disability was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In the rationale, the examiner stated that the medical and service treatment records provided for review lack demonstrable evidence of related symptoms or diagnosis during a period of active duty service. The first documentation of symptomology found was in 2017.

However, the Board finds the VA examiner's opinion to be inadequate for purposes of
and arm conditions examination the examiner diagnosed myofascial pain syndrome of trapezius and rhomboid musculature. The Veteran stated that his symptoms began in 2007 due to constantly carrying overweight items.

However, the Board finds the VA examiner's opinion to be inadequate for purposes of adjudicating the Veteran's claim. The examiner improperly relied solely on the absence of documentation or objective evidence of complaints, treatment, or diagnoses involving the left shoulder, without addressing the significance, if any, of the Veteran's reported lay history. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 note 1 (Fed. Cir. 2006) (noting that an examiner's opinion relying on the absence of contemporaneous medical evidence, "failed to consider whether the lay statements presented sufficient evidence of the etiology of [the veteran's] disability such that his claim of service connection could be proven"); Dalton v. Nicholson, 21 Vet. App. 23, 39 (2007) (finding an examination inadequate where the examiner "impermissibly ignored the appellant's lay assertions that he had sustained a back injury during service").

In an April 2024 private medical opinion Dr. N.P.D. indicated that the Veteran suffered from bilateral myofascial pain syndrome. The physician stated that the Veteran's primary symptoms included "constant pain in the neck and bilateral shoulder regions, specifically the bilateral trapezius and rhomboid muscles." He explained that these symptoms were "associated with weakness after repeated use, particularly reaching overhead and away from the body." The physician reviewed the January 2023 VA examination noting that the Veteran was found to have a decreased range of motion on flexion and abduction of the shoulder joint, but that plain radiographs of the bilateral shoulders which were both negative. However, an MRI of the cervical region of the spine conducted in 2017 showed central canal stenosis. The physician stated that Veteran's duties as an armor crewman included the handling of heavy-weighted machinery. Noting that the Veteran stated the onset of his symptoms occurred during service, the physician opined that his diagnosed bilateral shoulder myofascial pain "is at least as likely as not due to the arduous physical tasks he performed as a member of a military armor crewman."

In this regard, upon consideration of the Veteran's MOS and affording him the benefit of the doubt, the Board finds that the Veteran's reports of his physical duties and in-service left shoulder pain are consistent with the places, types, and circumstances of his service, specifically his MOS as an armor crewman. 38 U.S.C. § 1154(a); 38 C.F.R. § 3.303(a) (each disabling condition for which a veteran seeks service connection must be considered based on factors including the basis of places, types, and circumstances of service as shown by service record). Thus, the in-service injury or disease requirement is met.

On review, the Board is satisfied that the requirements for an award of service connection have been satisfied. The evidence, at a minimum, gives rise to a reasonable doubt on the matter. 38 C.F.R. § 3.102. The appeal of this issue is granted.

REASONS FOR REMAND

Service connection for a cervical spine disability is remanded.

The Veteran seeks to establish service connection for a cervical spine disability. He contends that he experienced neck pain since 2007.

The service treatment records are void of any findings, complaints, symptoms, or diagnosis related to any cervical spine disability or the neck.

VA medical records include a November 2016 report which shows the Veteran complained of neck pain since falling off a horse 3 days previously. Notably, this is 8 years after separation from service. In May 2017, the Veteran reported chronic pain in neck radiating to both shoulders and numbness in the ulnar distribution in both arms. He mentioned trauma in back during military service. In July 2018, the Veteran reported chronic back spasms over the last 11 or 12 years.

On January 2023 VA neck conditions examination, the examiner diagnosed IVDS and radiculopathy of the upper extremities since January 2023. The Veteran stated that the disability began in 2007 due to carrying overweight items.

In a January
report which shows the Veteran complained of neck pain since falling off a horse 3 days previously. Notably, this is 8 years after separation from service. In May 2017, the Veteran reported chronic pain in neck radiating to both shoulders and numbness in the ulnar distribution in both arms. He mentioned trauma in back during military service. In July 2018, the Veteran reported chronic back spasms over the last 11 or 12 years.

In a January 2023 medical opinion, the VA examiner opined that the Veteran's neck disability was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In the rationale, the examiner stated that the medical and service treatment records provided for review lack demonstrable evidence of related symptoms or diagnosis during a period of active-duty service. The first documentation of symptomology found was in 2017.

However, the Board finds the VA examiner's opinion to be inadequate for purposes of adjudicating the Veteran's claim. In arriving at an opinion, the examiner appears to have improperly relied solely on the absence of documentation or objective evidence of complaints, treatment, or diagnoses involving cervical spine issues during service, without addressing the medical significance, if any, of the Veteran's reported lay history. See Buchanan and Dalton, supra.

In an April 2024 private medical opinion Dr. N.P.D. noted that the Veteran had a diagnosis of degenerative disc disease of the cervical spine. The Veteran reported that his symptoms began more than 10 years ago when he was enlisted in the Army. His primary symptom was sharp neck pain that radiated to his upper extremities. A cervical spine MRT that showed central canal stenosis at the C6-C7 level as well as multilevel foraminal stenosis. The examiner explained that, "The presence of musculoskeletal injuries among Veterans is well-documented in today's medical literature. The pathologic findings on the MRT are characteristic "wear and tear" findings and are most commonly found in individuals in their 6th or 7th decade of life.

Dr. N.P.D. opined that the Veteran's "degenerative disc disease of the cervical spine is at least as likely as not due to the arduous physical tasks he performed as a member of a military armor crewman." He stated that the Veteran "has no other history of physical trauma of the spine other than the activities he faced while enlisted in the United States Army." However, the Board finds that this statement is untrue as the record demonstrates that the Veteran fell off a horse in 2016 and sought treatment for his neck as a direct result of that fall. Given this finding, the Board concludes that Dr. N.P.D.'s opinion is based on an inaccurate factual premise and is inadequate on that basis.

Moving on to the remainder of the opinion, the Veteran stated that his neck condition started more than 10 years ago when he was on active duty. However, the examiner failed to address the fact that the Veteran had not been on active duty for 16 years at the time he made the statement, or that the medical records do not show complaints regarding neck pain until 2016.

After review, the Board finds that the January 2023 VA medical opinion and April 2024 private medical opinion are inadequate. Failure to obtain an adequate medical opinion represents a pre-decisional duty to assist error under the AMA and the Board is obligated to remand this claim.

The matter is REMANDED for the following action:

Obtain an addendum medical opinion from an appropriate clinician on the nature and etiology of the Veteran's claimed cervical spine disability. The need for an additional VA examination is left to the discretion of the examiner. The entire claims file, including a copy of this remand, must be made available for review by the examiner and such review should be noted in the examination report.

Following a review of the entire record, the examiner should provide a medical opinion addressing:

Whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that any diagnosed cervical spine disability began during active-duty service, or is related to an in-service event, injury, or disease.

The examiner must review all evidence within the claims file and should consider and address the Veteran's lay statements regarding onset of neck pain during service, the April 2024 private opinion that suggests onset of neck pain due to his activities as an armor crewman, and evidence of neck complaints prior to 2017.

The examiner must provide a
review by the examiner and such review should be noted in the examination report.

Following a review of the entire record, the examiner should provide a medical opinion addressing:

The examiner must provide a complete rationale for any opinions offered, citing to the examination findings or other evidence in the record, when necessary, to support the conclusions reached. If an opinion cannot be reached without resorting to speculation, the examiner must fully explain why that is so.

The Board advises that a lack of documentation of complaints or symptoms of the claimed disability while in service or in the treatment records, is not, on its own, a sufficient rationale for a negative opinion.

C.B. Iwanowski

Acting Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board T. Adams, 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.

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