INTERVERTEBRAL DISC SYNDROME (IVDS)

B. D. WATSON · 2026 · Case ID: A26032942

MIXED

Summary

The veteran served from November 1979 to November 1982 and received an honorable discharge. He appealed a February 2021 decision that denied service connection for hypertension secondary to PTSD and denied an increased rating for his back condition. The Board reviewed evidence including the veteran's service treatment records, VA examinations from 2019 and 2021, a February 2023 x-ray report, and lay statements from the veteran. For the back condition, the Board found that while the veteran had limitations and pain, his ranges of motion and functional impairments did not meet the criteria for a rating higher than 20 percent. The Board noted the veteran's employment history, including working as a laundry worker, EMS employee, and in manufacturing, suggesting his back condition did not prevent substantial gainful employment. The Board also considered the benefit of the doubt doctrine but found it inapplicable as the evidence weighed against the veteran's claim for an increased rating. For the hypertension claim, the Board found that while service treatment records did not show in-service hypertension, the veteran's PTSD and chronic pain were established as service-connected. A private physician's October 2024 statement provided a nexus, explaining how pain and PTSD can elevate blood pressure and citing studies supporting the link. The Board found this physician's opinion persuasive, satisfying the nexus requirement for secondary service connection. The Board also applied the benefit of the doubt doctrine to grant the hypertension claim. Therefore, service connection for hypertension secondary to PTSD was granted, and the claim for an increased rating for the back condition was denied.

Rationale

Veteran's ranges of motion (flexion 40 degrees, combined 140 degrees) and symptoms did not meet criteria for 40% rating.; No severe guarding resulting in abnormal gait or ankylosis.; Benefit of the doubt doctrine found inapplicable as evidence weighed against claim.

Special Benefit

NO SPECIAL BENEFIT

Docket No.

210506-157797

Full Decision Text

Citation Nr: A26032942
Decision Date: 04/09/26 Archive Date: 04/09/26

DOCKET NO. 210506-157797
DATE: April 9, 2026

ORDER

Entitlement to an evaluation in excess of 20 percent for a back condition is denied.

Entitlement to service connection for hypertension secondary to posttraumatic stress disorder (PTSD) is granted.

FINDINGS OF FACT

1. The Veteran was not prescribed bedrest for intervertebral disc syndrome (IVDS), did not have forward flexion limited to 30 degrees and did not have ankylosis.

2. The persuasive weight of the evidence weighed in favor of a finding that the Veteran's PTSD caused his hypertension or made his hypertension worse.

CONCLUSIONS OF LAW

1. The criteria for an evaluation in excess of 20 percent for a back condition have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5242.

2. The criteria for service connection for hypertension secondary to PTSD have been met. 38 U.S.C. § 1131; 38 C.F.R. §§ 3.102, 3.303

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from November 1979 until November 1982. He was honorably discharged.

This matter comes before the Board of Veterans' Appeals (Board) from a February 2021 decision issued by a Department of Veterans Affairs (VA) agency of original jurisdiction (AOJ) denying service connection for hypertension and an evaluation in excess of 20 percent for lumbar spine arthritis and IVDS (back condition). In May 2021, the Veteran filed VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement) (NOD) appealing the rating decision and electing the hearing docket. A Board hearing was held in July 2024, and a transcript of the hearing was associated with the claims file.

The Board may only consider the evidence of record at the time of the February 2021 decision on appeal, as well as any evidence submitted by the Veteran at the hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a). If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

1. Entitlement to an evaluation in excess of 20 percent for a back condition is denied.

The VA amended the criteria for rating musculoskeletal disabilities effective February 7, 2021. DC 5242 was changed to clarify that it applied to degenerative arthritis and degenerative disc disease other than IVDS (also, see either 5003 or 5010).

DC 5243, applicable to IVDS, was changed to clarify that it is only to be assigned when there is disc herniation with compression and/or irritation of the adjacent nerve root, and that DC 5242 should be assigned for all other disc diagnoses.

The rating criteria under DC 5003 did not change on February 7, 2021; however, the DC was changed to clarify that it only applied to degenerative arthritis, other than post-traumatic. Post-traumatic arthritis is separately rated under DC 5010. Pursuant to the February 2021 amendment, DC 5010 should be rated as limitation of motion, dislocation, and other specified instability of the affected joint; if there are two or more joints affected, each rating shall be combined in accordance with 38 C.F.R. § 4.25. As noted above, DC 5243 should be assigned "only when there is disc herniation with compression and/or irritation of the adjacent nerve root" with DC 5242 to be assigned for all other diagnoses. Otherwise, the rating criteria for disease and injuries of the back remain unchanged.

Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. Regulations specify that disabilities of the spine should be evaluated under the General Rating Formula for Diseases and Injuries of the Spine (Spinal Formula). 38 C.F.R. § 4.71a, Diagnostic Codes 5235 to 5243. When IVDS is present, it is to be evaluated under the Spinal Formula unless it is more favorable
4.25. As noted above, DC 5243 should be assigned "only when there is disc herniation with compression and/or irritation of the adjacent nerve root" with DC 5242 to be assigned for all other diagnoses. Otherwise, the rating criteria for disease and injuries of the back remain unchanged.

Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. Regulations specify that disabilities of the spine should be evaluated under the General Rating Formula for Diseases and Injuries of the Spine (Spinal Formula). 38 C.F.R. § 4.71a, Diagnostic Codes 5235 to 5243. When IVDS is present, it is to be evaluated under the Spinal Formula unless it is more favorable to rate under the Formula for Rating IVDS based on incapacitating episodes (IVDS Formula). Ratings under the Spinal Formula are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease.

The General Spinal Rating Formula provides for a 10 percent rating when forward flexion of the thoracolumbar spine is greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine is greater than 120 degrees but not greater than 235 degrees; or, with muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height.

A 20 percent rating is warranted when forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees, when the combined range of motion of the thoracolumbar spine is not greater than 120 degrees, or when muscle spasm or guarding is severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis.

A 40 percent rating is assigned when forward flexion of the thoracolumbar spine is 30 degrees or less, or with favorable ankylosis of the entire thoracolumbar spine.

A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine and a 100 percent rating is assigned with unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula.

Alternatively, IVDS can be rated based on incapacitating episodes under the IVDS Formula Based on Incapacitating Episodes or the General Rating Formula, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. Id. at Note (6). For example, a 10 percent evaluation is warranted when a Veteran has had incapacitating episodes with a total duration of at least one week but less than two weeks during the past 12 months. Incapacitating episodes with a total during of two weeks but less than four weeks in the last 12 months warrants a 20 percent evaluation. Incapacitating episodes with total duration of four weeks but less than six weeks in the last 12 months warrants a 40 percent.

For VA compensation purposes, normal forward flexion of the thoracolumbar spine is to 90 degrees, and the normal combined range of motion is 240 degrees. Id. at Note (2). Associated objective neurologic abnormalities should be rated separately under an appropriate diagnostic code. Id. at Note (1).

When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also to be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40
App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria.").

In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint." The spine has no opposite joint.

In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination.

A February 2023 x-ray report provided by the Veteran within 90 days following his Board hearing reflected that he had very mild scoliotic curvature of his thoracolumbar spine, mild to moderate degenerative joint disease, most severe at L-5 to S-1, and moderate disc space narrowing, vacuum disc phenomemon and bridging spur formation at L5-S1. lumbar

A February 2021 VA emergency treatment record noted that the Veteran could return to his job with no restrictions. The January 2021 thoracolumbar examination report noted 1980 diagnoses of degenerative arthritis and IVDS. He advised the examiner that he was stiff when he woke up in the morning and required a heating pain to "loosen up" enough to get up to walk. He also had tingling and numbness in both legs. The Veteran described his functional impairment as an inability to walk, run, play sports, or sit for long periods. The Veteran's active range of motion was to 40 degrees, and his extension was to 20 degrees. His right lateral flexion left lateral flexion, right lateral rotation, and left lateral rotation were all to 20 degrees. His combined ranges of motion were 140 degrees.

After three repetitions, the Veteran had a five-degree range of motion loss for each range of motion. The factors that caused this loss of motion were pain, fatigue, weakness, lack of endurance and incoordination. The examiner estimated that the Veteran's ranges of motion after repeated use would remain the same as after three repetitions. The examiner noted that passive range of motion testing was contraindicated.

The examiner noted that the Veteran had guarding which resulted in an abnormal gait. The Veteran had loss of muscle strength with hip flexion and knee flexion bilaterally. He did not have any muscle atrophy, no ankylosis, and his reflexes were normal. His sensory examination reflected decreased sensation bilaterally. The Veteran stated that he constantly used a wheelchair, brace and walker. The Board notes that during the hearing the Veteran testified that he used a walker and sometimes used a wheelchair. Hearing Transcript, pp. 5. The Board notes that while the VA provided these assistive devices to the Veteran, the record did not reflect a prescription for these devices or other indication that they were medically necessary. The Veteran stated he was working for approximately two hours per day doing light housekeeping. He had missed one to two weeks of work in the previous year.

The examiner noted evidence of localized pain on palpitation of the joint or associated soft tissue of the back and pain with non-weight bearing. The record did not have evidence of physician prescribed bed rest for IVDS. Accordingly, it is more beneficial to rate the Veteran under the general spine formula.

The November 2019 VA thoracolumbar examiner noted diagnoses of degenerative arthritis and IVDS. The Veteran's ranges of motion were to 45 degrees for flexion, and to 20 degrees for all other ranges of motion. There was no additional loss of range of motion after three repetitions. The Veteran described his functional impairment as an inability to play sports or bowl, and that he could not take long walks, bend over much, or sit for long periods of time. No guarding was observed and the Veteran's gait was normal. His reflexes were also normal, and he had not been prescribed bedrest in the last 12 months for IVDS. The examiner noted that his functional impact was with bending, lifting, sitting and walking.

During this examination he had full muscle strength, normal reflexes, no muscle atrophy, no ankylosis, and a normal sensory examination. Pain was observed with all ranges of motion. The Veteran stated that he used a wheeled walker for his back. His October 2019 x-rays reflected that his lumbar vertebrae maintained a stable height and alignment and there were degenerative endplate changes at multiple levels.

As noted above, a 20 percent rating is warranted when forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees, when the combined range of motion of the thoracolumbar spine is not greater than 120 degrees, or when muscle spasm or guarding is severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis.

The 2021 February VA back examination report reflected that the Veteran's back condition had declined from his 2019 VA back examination. In February 2021, his active range of motion for flexion was 40 degrees, and his extension was to 20 degrees. His right lateral flexion left lateral flexion, right lateral rotation, and left lateral rotation were all to 20 degrees. His combined ranges of motion were 140 degrees. After three repetitions he lost five degrees of motion for all ranges. In November 2019, the Veteran's ranges of motion were to 45 degrees for flexion, and to 20 degrees for all other ranges of motion. There was no additional loss of range of motion after three repetitions.

While his examinations reflected some decline between 2019 and 2021, his ranges of motions from both 2019 and 2021 warranted a 20 percent evaluation. He did not have forward flexion limited to 30 degrees or less and did not have ankylosis. A 40 percent rating is assigned when forward flexion of the thoracolumbar spine is 30 degrees or less, or with favorable ankylosis of the entire thoracolumbar spine. As the Veteran did not meet the rating criteria for a 40 percent evaluation, he is appropriately rated at 20 percent based on the evidence in the record.

Disability ratings are determined by the application of a schedule of ratings that is based on average impairment of earning capacity. 38 U.S.C. § 1155. Percentage ratings are determined by comparing the manifestations of a particular disability with the requirements contained in VA's Schedule for Rating Disabilities. The percentage ratings contained in the Rating Schedule represent, as far as can practically be determined, the average impairment in earning capacity resulting from a disease or injury and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1.

Included in records the Veteran submitted to the Board within 90 days of his hearing were March and August 2022 mental health treatment records which noted the Veteran was working as an emergency medical service (EMS) employee and occasionally was late because he had to drive early in the morning. A September 2020 psychiatry record noted that the Veteran was offered a housekeeping job. In February 2020, the Veteran advised his VA primary care physician that he needed a form completed so that he could drive a forklift truck. The provider noted that the Veteran did not bring his walker to the appointment. The Veteran stated that his back pain was increasing and he was working 12-hour shifts three out of every four days in manufacturing. A December 2019 psychiatry record noted the Veteran was working for a manpower company. A mid-July 2018 audiology record noted that the Veteran was employed full time as a laundry service worker. July and August
occasionally was late because he had to drive early in the morning. A September 2020 psychiatry record noted that the Veteran was offered a housekeeping job. In February 2020, the Veteran advised his VA primary care physician that he needed a form completed so that he could drive a forklift truck. The provider noted that the Veteran did not bring his walker to the appointment. The Veteran stated that his back pain was increasing and he was working 12-hour shifts three out of every four days in manufacturing. A December 2019 psychiatry record noted the Veteran was working for a manpower company. A mid-July 2018 audiology record noted that the Veteran was employed full time as a laundry service worker. July and August 2018 VA mental health records noted that the Veteran's employment was terminated due to marijuana use in December 2017 from his job of 11 years at a hospital.

While the Veteran has had a variety of jobs, the record reflected that he maintained employment and that his back condition did not prevent him from maintaining jobs as a laundry worker, housekeeping, EMS employee, work in a manufacturing environment and in 2020 he considered himself able to perform a forklift driving job.

The persuasive weight of the evidence weighs against a finding that the Veteran's back condition caused an impairment in excess of a 20 percent evaluation. The Board has considered the benefit of the doubt doctrine and determined it is not applicable. As the evidence is persuasively against the Veteran's claim for an evaluation in excess of 20 percent for a back condition, the evidence is not in approximate balance, and the benefit of the doubt rule does not apply. Therefore, the claim must be denied. See 38 U.S.C. § 5107(b); 38 CFR § 3.102; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021).

2. Entitlement to service connection for hypertension secondary to PTSD is granted.

Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d).

Secondary service connection may be granted for a disability which is proximately due to or the result of an established service-connected disease. 38 C.F.R. §§ 3.310 (a)-(b); 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a); Allen v, Brown, 7 Vet. App. 439 (1995). When service connection is established for a secondary condition, the secondary condition shall be considered part of the original condition. Id. A medical nexus opinion must state whether the claimed condition was caused by or aggravated by the service-connected condition. El-Amin v. Shinseki, 26 Vet. App. 136 (2013); 38 U.S.C. § 1110.

Secondary aggravation exists when the non-service-connected disability was not caused by a service-connected disability but would be less severe were it not for a service-connected disability. Spicer v. McDonough, 61 F.4th 1360, 1364 (Fed. Cir. 2023).

Certain chronic diseases may be service-connected on a presumptive basis if manifested to a compensable degree within a specified period following separation from service (generally one year). 38 U.S.C. §§ 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. For chronic diseases listed in 38 C.F.R. § 3.309(a), nexus to service may be established by showing continuity of symptomatology since service. Walker v. Shinseki, 708 F.3d 1331, 1338-40 (Fed. Cir. 2013). Arthritis is considered a "chronic disease" under 38 C.F.R. § 3.309 (a). Spondylosis is defined as degenerative spinal changes due to osteoarthritis (Dorland's Illustrated Medical Dictionary, 32nd ed., 2012
1112, 1137; 38 C.F.R. §§ 3.307, 3.309. For chronic diseases listed in 38 C.F.R. § 3.309(a), nexus to service may be established by showing continuity of symptomatology since service. Walker v. Shinseki, 708 F.3d 1331, 1338-40 (Fed. Cir. 2013). Arthritis is considered a "chronic disease" under 38 C.F.R. § 3.309 (a). Spondylosis is defined as degenerative spinal changes due to osteoarthritis (Dorland's Illustrated Medical Dictionary, 32nd ed., 2012). Therefore, the presumptive provisions of 38 C.F.R. § 3.303 (b) for "chronic" in-service symptoms and "continuous" post-service symptoms apply. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).

For a showing of a chronic disease in service, the mere use of the word "chronic" will not suffice; rather, there is a required combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings. 38 C.F.R. § 3.303(b). Continuity of symptomatology after service is required where a condition noted during service is not, in fact, chronic, or where a diagnosis of chronicity may be legitimately questioned. Id. The presumptive service connection provisions based on "chronic" in-service symptoms and "continuity of symptomatology" after service under 38 C.F.R. § 3.303(b) have been interpreted as an alternative to service connection only for the specific chronic diseases listed in 38 C.F.R. § 3.309 (a). See Walker v. Shinseki, 718 F.3d 1331 (Fed. Cir. 2013) (holding that the "chronic" in service and "continuous" post-service symptom presumptive provisions of 38 C.F.R. § 3.303 (b) only apply to "chronic" diseases at 3.309(a)).

Lay assertions may serve to support a claim for service connection by establishing the occurrence of observable events or the presence of disability or symptoms of disability that are subject to lay observation. 38 U.S.C. § 1153 (a); 38 C.F.R. § 3.303 (a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence).

Depending on the evidence and the contentions of record in a particular case, lay evidence can be competent and sufficient to establish a diagnosis and medical etiology of a condition. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Specifically, lay evidence may be competent and sufficient to establish a diagnosis where (1) a layperson is competent to identify the medical condition, (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. Jandreau, 492 F.3d at 1377.

Additionally, where symptoms are capable of lay observation, a lay witness is competent to testify to a lack of symptoms prior to service, continuity of symptoms after in-service injury or disease, and receipt of medical treatment for such symptoms. Charles v. Principi, 16 Vet. App. 370, 374 (2002). Lay testimony is not competent to determine the extent or etiology of matters which require medical testing and expertise to determine. See Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007); Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011).

The claimant has the responsibility to present and support a claim for benefits. 38 U.S.C. § 5107(a). The VA shall consider all information, including lay and medical evidence of record. VA is responsible for determining whether the evidence persuasively favors one side or another. 38 C.F.R. § 4.3. When there is an approximate or nearly equal balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the Veteran and the claim will be granted on the merits. 38 U.S.C. § 5107(b). When the evidence persuasively favors against the claims of the Veteran, the benefit of the doubt doctrine is inapplicable, and the claim will be denied on its merits. 38 U.S.C. § 5107; Lynch v. McDonough, 21 F.4th 776, 781-82 (Fed. Cir. 2021).

The first element of service connection is a current disability. The February 2021 rating decision conceded that the Veteran has a current disability of hypertension. The Board is bound by this favorable finding. 38 C.F.R. § 3.104. Thus, the Board finds the first element of service connection is satisfied.

The second element of service connection is an inservice injury. The Veteran's service treatment records did not contain any evidence of high blood pressure readings or a diagnosis of hypertension. The record also did not contain any evidence of a diagnosis of hypertension or high blood pressure readings within one year of separation from service. Accordingly, the Veteran is not entitled to a presumption of service connection for hypertension under a theory of chronicity of symptomatology. 38 C.F.R. § 3.303 (b). As there was no evidence of an in-service illness of hypertension, the second element of service connection on a direct basis is not satisfied.

The Veteran is service connected for PTSD and contended that his hypertension is secondary to his PTSD. The February 2021 rating decision conceded that the Veteran met the second element of service connection on a secondary basis. The Board is bound by this favorable finding. 38 C.F.R. § 3.104. Thus, the Board finds the second element of service connection is satisfied.

The third element of service connection is a nexus between the first two elements. The Veteran submitted an October 2024 physician statement addressing the effect of pain and PTSD on hypertension. The Veteran advised this physician that he had chronic pain from his back condition. The physician explained that pain activates the body's stress response, which involves the hypothalamic, pituitary, adrenal axis and the sympathetic nervous system. This releases cortisol and catecholamines, which can increase blood pressure. Persistent discomfort can lead to stress, anxiety, and depression, which are known to affect cardiovascular health. The constant burden of chronic pain often disrupts sleep patterns, decreases physical activity, and can contribute to an overall decline in quality of life. These factors, in turn, may indirectly influence blood pressure regulation. The physician cited several medical articles and studies to support the connection between hypertension and a psychiatric reaction as a result of pain.

With regard to PTSD, the physician noted that multiple studies have shown that physiological responses (increase in heart rate, blood pressure, tremor and other symptoms of autonomic arousal) to reminders of the trauma are a part of PTSD. Multiple studies have shown that patients suffering from PTSD have increased resting heart rate, increased startle reaction, and increased heart rate and blood pressure as responses to traumatic slides, sounds and scripts. The physician cited to several medical articles which discussed medical studies and results to support the opinion that the Veteran's hypertension was at least as likely as not due to his PTSD and/or chronic pain. The Board finds that the third element of service connection, the nexus requirement, has been satisfied.

As the three elements of service connection have been satisfied, the persuasive weight of the evidence weighs in favor of finding that the Veteran's hypertension is secondary to his PTSD.

(continued on next page)

In reaching such a determination, the Board considered the applicability of the benefit of the doubt doctrine. That doctrine is applicable in the instant appeal, and his claim for service-connection for hypertension secondary to his PTSD must be granted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch v. McDon
was at least as likely as not due to his PTSD and/or chronic pain. The Board finds that the third element of service connection, the nexus requirement, has been satisfied.

As the three elements of service connection have been satisfied, the persuasive weight of the evidence weighs in favor of finding that the Veteran's hypertension is secondary to his PTSD.

(continued on next page)

B. D. WATSON

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board W. Polk

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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