DEGENERATIVE ARTHRITIS OF THE SPINE (SPONDYLOSIS)

Summary

The veteran served from October 2003 to December 2008. The veteran appeals the denial of service connection for several conditions and seeks service connection for others. The Board granted service connection for degenerative disc disease of the lumbar spine, bilateral patellofemoral syndrome, bilateral ankle sprain, bilateral foot disability, left fifth toe strain, deviated nasal septum, residuals of an epididymectomy, chronic headache disability, and generalized anxiety disorder. The Board found that the evidence, when resolving reasonable doubt in the veteran's favor, established a relationship between the claimed conditions and active service. For the low back, bilateral knee, bilateral ankle, bilateral foot, left fifth toe, deviated nasal septum, residuals of epididymectomy, chronic headache, and psychiatric disorder claims, the Board applied the benefit of the doubt doctrine due to a continuity of symptoms since service, despite a lack of post-service treatment records and conflicting VA medical opinions. The Board found the veteran's testimony regarding continuity of symptoms credible and adequately explained the lack of post-service medical records due to ineligibility for VA care and lack of insurance. The Board concluded that service connection was warranted for all claimed conditions.

Rationale

Continuity of symptoms since service; Benefit of the doubt applied; Lack of post-service treatment adequately explained

Full Decision Text

Citation Nr: 22042513
Decision Date: 07/27/22	Archive Date: 07/27/22

DOCKET NO. 16-45 031
DATE: July 27, 2022

ORDER

Service connection for degenerative disc disease of the lumbar spine is granted.

Service connection for bilateral patellofemoral syndrome is granted.

Service connection for a bilateral ankle sprain is granted.

Service connection for a bilateral foot disability is granted.

Service connection for a left fifth toe strain is granted.

Service connection for a deviated nasal septum is granted.

Service connection for the residuals of an epididymectomy is granted.

Service connection for a chronic headache disability is granted.

Service connection for generalized anxiety disorder is granted.

FINDINGS OF FACT

1. Resolving reasonable doubt in the Veteran's favor, his low back disability is related to active service.

2. Resolving reasonable doubt in the Veteran's favor, his bilateral knee disability is related to active service.

3. Resolving reasonable doubt in the Veteran's favor, his bilateral ankle disability is related to active service. 

4. Resolving reasonable doubt in the Veteran's favor, his bilateral foot disability is related to active service. 

5. Resolving reasonable doubt in the Veteran's favor, his left fifth toe disability is related to active service. 

6. Resolving reasonable doubt in the Veteran's favor, his deviated nasal septum is related to active service. 

7. Resolving reasonable doubt in the Veteran's favor, he has residuals of an in-service epididymectomy. 

8. Resolving reasonable doubt in the Veteran's favor, his chronic headache disability is related to active service.

9. Resolving reasonable doubt in the Veteran's favor, his psychiatric disorder is related to active service. 

CONCLUSIONS OF LAW

1. The criteria for service connection for degenerative disc disease of the lumbar spine are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303.

2. The criteria for service connection for bilateral patellofemoral syndrome are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303.

3. The criteria for service connection for a bilateral ankle sprain are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303.

4. The criteria for service connection for a bilateral foot disability are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303.

5. The criteria for service connection for a left fifth toe strain are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303.

6. The criteria for service connection for a deviated nasal septum are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303.

7. The criteria for service connection for the residuals of an epididymectomy are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303.

8. The criteria for service connection for a chronic headache disability are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 

9. The criteria for service connection for generalized anxiety disorder are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran had active service from October 2003 to December 2008. In November 2021, the Veteran testified at a Board of Veterans' Appeals (Board) hearing before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the claims file.

Service Connection

Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection requires competent evidence of (1) a current disability; (2) the incurrence or aggravation
1, the Veteran testified at a Board of Veterans' Appeals (Board) hearing before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the claims file.

Service Connection

Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection requires competent evidence of (1) a current disability; (2) the incurrence or aggravation of a disease or injury during service; and (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). 

Low Back

Service treatment records show that in March 2004 the Veteran complained of pain in the right lower extremity. While he initially denied low back pain, examination revealed pain on extension of the thoracolumbar spine. He was diagnosed with lumbosacral radiculitis/piriformis syndrome. May 2004 records show complaints of low back pain radiating into the right lower extremity for the past two months. Examination revealed muscle spasms. June 2004 records show complaints of low back pain, diagnoses of sciatica and possible piriformis syndrome and a plan to continue with pain medication and medication for muscle spasms. The Veteran was placed on a profile of no running, jumping or lifting over 20 pounds for 30 days. A January 2008 record shows complaints of low back pain radiating into both lower extremities for the past week. Examination revealed muscle spasms and he was prescribed medication for muscle spasms. A February 2008 record reflects that he was still taking medication for muscle spasms. The September 2008 separation examination revealed a normal spine.

At a June 2017 VA examination, the Veteran reported that he injured his low back during service performing his usual duties. The examiner noted that the service treatment records show that the Veteran was treated for his low back but that there is no post service treatment record until 2016. 

In a July 2017 medical opinion, another VA examiner reviewed the claims file and stated that there is no credible evidence of a chronic low back condition in service or during a valid period after discharge. The examiner stated that a lag in treatment negates any continuity of care or symptomatology. The examiner then concluded that the Veteran's low back disability was not incurred in or caused by service.

Initially, while the VA examiner did not provide a diagnosis of the Veteran's low back disability, the Board notes that VA treatment records show that January 2018 X-rays of the lumbar spine revealed degenerative disc disease. 

While the Board appreciates the examiner's opinion, it was based on a lack of post service treatment records. The Board observes that a continuity of symptoms, not treatment, is required to support a claim for service connection. The Veteran filed his initial claim for service connection for a low back disability in January 2010, just over a year of his discharge from active service. Moreover, in an April 2018 statement, the Veteran explained the lack of post service medical records by stating that he was not eligible for VA medical care and did not have insurance to pay for private medical care. Nevertheless, he testified that he has had low back problems since service. The Veteran is competent to give evidence about observable symptoms such as low back pain. Layno v. Brown, 6 Vet. App. 465 (1994). Thus, resolving reasonable doubt in his favor, the Board finds that his low back disability is related to active service. 38 U.S.C. § 5107(b) (2012). The Board concludes that service connection for degenerative disc disease of the lumbar spine is warranted.

Bilateral knee disability 

Service treatment records show that in March 2005 the Veteran complained of bilateral knee pain, noting that he works as a mechanic and frequently bends and stoops. He was diagnosed with bilateral patellofemoral syndrome and placed on a profile of no running, jumping, kneeling or stooping for one month. April 2005 records show complaints of ongoing bilateral knee pain, noting mechanic duties as well as a history of bilateral knee pain since basic training. An August 2005 record shows that the Veteran injured his right knee when he fell and struck the knee on the ground during a panic attack. A January 2007 record notes left knee pain for the past three months. The Veteran reported bilateral knee pain at his September 2008 separation examination. While examination revealed normal knees, the
2005 the Veteran complained of bilateral knee pain, noting that he works as a mechanic and frequently bends and stoops. He was diagnosed with bilateral patellofemoral syndrome and placed on a profile of no running, jumping, kneeling or stooping for one month. April 2005 records show complaints of ongoing bilateral knee pain, noting mechanic duties as well as a history of bilateral knee pain since basic training. An August 2005 record shows that the Veteran injured his right knee when he fell and struck the knee on the ground during a panic attack. A January 2007 record notes left knee pain for the past three months. The Veteran reported bilateral knee pain at his September 2008 separation examination. While examination revealed normal knees, the examiner noted a diagnosis of bilateral patellofemoral syndrome.

At a June 2017 VA examination, the Veteran reported that he injured his knees during service performing his usual duties. The examiner noted that the service treatment records show that the Veteran was treated for his knees on numerous occasions but not diagnosed with a knee disorder. The examiner noted that the Veteran has not been treated for his knees since discharge from service. The examiner provided a diagnosis of bilateral patellofemoral syndrome.

In a July 2017 medical opinion, another VA examiner reviewed the claims file and found no credible evidence of a chronic knee condition in service or during a valid period after discharge. The examiner stated that a lag in treatment negates any continuity of care or symptoms. The examiner then concluded that the Veteran's bilateral patellofemoral syndrome was not incurred in or caused by service.

While the Board appreciates the examiner's opinion, it again was based on a lack of post service treatment records. However, the Board reiterates that a continuity of symptoms, not treatment, is required to support a claim for service connection. Contrary to the examiner's observation, the service treatment records do support the presence of a chronic bilateral knee condition, even on separation examination. The Veteran filed his initial claim for service connection for a bilateral knee disability in January 2010, just over a year after his discharge. He attributed the lack of post service medical records to his ineligibility for VA medical care and lack of health insuranceand testified that he has had bilateral knee pain since service. Resolving reasonable doubt in his favor, the Board finds that his bilateral knee disability is related to active duty. 38 U.S.C. § 5107(b). The Board concludes that service connection for bilateral patellofemoral syndrome is warranted.

Bilateral ankle disability 

Service treatment records show that in February 2004 the Veteran complained of bilateral ankle pain for the past month and was diagnosed with bilateral foot/calf pain. He was placed on a profile of no running, jumping or forced marching for two weeks. A June 2005 record reflects that he injured his left ankle when he fell a week ago, and X-rays showed a questionable fracture of the talus. An August 2005 record reflects that he injured his left ankle when he fell during a panic attack. A December 2005 record shows complaints of left ankle pain after someone stepped on his foot and a diagnosis of left ankle trauma, rule out fracture. X-rays were normal. The September 2008 separation examination revealed normal ankles.

At a June 2017 VA examination, the Veteran reported that he injured his ankles during service performing his usual duties. The examiner noted that the service treatment records show that the Veteran was treated for his left ankle on numerous occasions but that post-service medical records were negative for ankle complaints. The examiner diagnosed a left ankle sprain.

In a July 2017 medical opinion, another VA examiner reviewed the claims file and stated that there is no credible evidence of a chronic ankle condition in service or during a valid period after discharge. The examiner stated that a lag in treatment negates any continuity of care or symptomatology. The examiner then concluded that the Veteran's left ankle sprain was not incurred in, or caused by, his service.

Initially, the Board notes that the AOJ only requested a medical opinion on the Veteran's left ankle. As such, the examiner only provided an opinion on the left ankle. Thus, while the examiner did not diagnose the Veteran with a right ankle sprain, given the similar complaints and findings with respect to the right ankle, and the examiner's diagnosis of a sprain for the left ankle, the Board will resolve reasonable doubt in the Veteran's favor and find that he also has a right ankle sprain. 38 U.S.C. § 5107(b). This finding is supported by the Veteran's testimony that he has had bilateral ankle pain and swelling since service, which indicates the presence of current disability in both ankles.

While the Board appreciates the examiner's opinion, it again was based on a lack of post service treatment records. However, the Board reiterates that a continuity of symptoms, not treatment,
 Thus, while the examiner did not diagnose the Veteran with a right ankle sprain, given the similar complaints and findings with respect to the right ankle, and the examiner's diagnosis of a sprain for the left ankle, the Board will resolve reasonable doubt in the Veteran's favor and find that he also has a right ankle sprain. 38 U.S.C. § 5107(b). This finding is supported by the Veteran's testimony that he has had bilateral ankle pain and swelling since service, which indicates the presence of current disability in both ankles.

While the Board appreciates the examiner's opinion, it again was based on a lack of post service treatment records. However, the Board reiterates that a continuity of symptoms, not treatment, is required to support a claim for service connection. While the service treatment records only contain one entry showing complaints of right ankle pain, the Veteran is competent to say that he had ongoing right ankle pain during service. Layno, 6 Vet. App. 465. The Veteran filed his initial claim for service connection for a bilateral ankle disability in January 2010, just over a year after his discharge, and he attributed the lack of post service medical records to his ineligibility for VA medical care and a lack of health insurance. He also testified that he has had bilateral ankle problems, particularly swelling, since service. Thus, resolving reasonable doubt in the Veteran's favor, the Board finds that his bilateral ankle disability is related to active service. 38 U.S.C. § 5107(b). Accordingly, the Board concludes that service connection for a bilateral ankle sprain is warranted. 

Bilateral foot disability 

Service treatment records show that in February 2004 the Veteran complained of bilateral foot pain for the past month and was diagnosed with bilateral foot pain. A December 2005 record shows complaints of left foot pain after someone stepped on his foot. The September 2008 separation examination revealed normal feet.

At a June 2017 VA examination, the Veteran reported developing left foot pain during service performing his usual duties. He reported daily foot pain with flare-ups once per month that last for two days. He denied any functional loss but stated that his left foot hurts very badly. The examiner noted that the service treatment records show that the Veteran was treated for his left foot but that the Veteran has not been treated for his foot since discharge from service. The examiner diagnosed a left ankle sprain. In a July 2017 medical opinion, another VA examiner reviewed the claims file and stated that there is no credible evidence of a chronic foot condition in service or during a valid period after discharge. The examiner stated that a lag in treatment negates any continuity of care or symptomatology. The examiner then concluded that the Veteran's bilateral foot disability was not incurred in or caused by service.

Initially, the Board notes that the examiner focused on the left foot. Nevertheless, the examiner provided a diagnosis of a bilateral foot pain based in part on the Veteran's complaints at the examination which indicated the presence of current disability in both feet. In that regard, the Board notes that disability refers to the functional impairment of earning capacity and pain in the absence of a presently-diagnosed condition can cause functional impairment. Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). The Board observes that the Veteran's complaints of foot pain with flare-ups lasting for two days suggest functional impairment of earning capacity. While the examiner indicated that the Veteran denied having functional loss, the examiner noted his report that his left foot hurts very badly, which again suggests functional impairment of earning capacity. The Board resolves reasonable doubt in the Veteran's favor and find that he has a bilateral foot disability. 38 U.S.C. § 5107(b). [The AOJ is advised that further examination may be warranted to obtain a more specific diagnosis of the Veteran's bilateral foot disability.]

While the Board appreciates the examiner's opinion, it was based on a lack of post service treatment records. Continuity of symptoms, not treatment, is required to support a claim for service connection. The Veteran filed his initial claim for service connection for a bilateral foot disability in January 2010, just over a year after his discharge, and he adequately explained the lack of post service medical records. He testified that he has had bilateral foot problems since service. Thus, resolving reasonable doubt in the Veteran's favor, the Board finds that his bilateral foot disability is related to active service. 38 U.S.C. § 5107(b). Accordingly, the Board concludes that service connection for a bilateral foot disability is warranted.

Left fifth toe disability 

Service treatment records show that in December 2005 the Veteran complained of left foot pain after someone stepped on his foot, specifically the toes. Examination revealed pain and swelling and decreased range of motion, particularly of the fifth toe. He was diagnosed with left foot trauma, rule out fracture. X
0, just over a year after his discharge, and he adequately explained the lack of post service medical records. He testified that he has had bilateral foot problems since service. Thus, resolving reasonable doubt in the Veteran's favor, the Board finds that his bilateral foot disability is related to active service. 38 U.S.C. § 5107(b). Accordingly, the Board concludes that service connection for a bilateral foot disability is warranted.

Left fifth toe disability 

Service treatment records show that in December 2005 the Veteran complained of left foot pain after someone stepped on his foot, specifically the toes. Examination revealed pain and swelling and decreased range of motion, particularly of the fifth toe. He was diagnosed with left foot trauma, rule out fracture. X-rays were normal. The September 2008 separation examination revealed a normal left foot. At a post-service June 2017 VA examination, the Veteran reported developing left foot pain during service performing his usual duties. The examiner noted that the service treatment records show that the Veteran was treated for his left foot and diagnosed with a strain of the fifth toe. The examiner noted that the Veteran has not been treated for his left foot since discharge from service. The examiner provided a diagnosis of a left fifth toe strain.

In a July 2017 medical opinion, another VA examiner reviewed the claims file and stated that there is no credible evidence of a chronic left fifth toe condition in service or during a valid period after discharge. The examiner stated that a lag in treatment negates any continuity of care or symptoms. The examiner concluded that the Veteran's left fifth toe strain was not incurred in or caused by service.

While the Board appreciates the examiner's opinion, it again was based on a lack of post service treatment records. Again, only a continuity of symptoms is required to support a claim for service connection. The Veteran filed his initial claim for service connection for a left fifth toe disability in January 2010, just over a year after his discharge, and he adequately explained the lack of post service medical records. He also testified that he has had problems with his left fifth toe, including numbness, since service. Resolving reasonable doubt in the Veteran's favor, the Board finds that his left fifth toe disability is related to active duty. 38 U.S.C. § 5107(b). Thus, service connection for a left fifth toe strain is warranted.

Deviated nasal septum

Service treatment records show that in February 2004 the Veteran slipped on ice and fell face-first onto the ground, suffering a laceration on the bridge of his nose. Examination revealed swelling of the nose and a small laceration. Rule out nasal fracture was diagnosed. Two weeks later, he complained of headaches for the past week that began after the fall. A May 2007 record shows that examination revealed a deviated nasal septum and a diagnosis of an acquired deviated nasal septum. A February 2008 record lists an acquired deviated nasal septum as an active problem.

At a June 2017 VA examination, the Veteran reported that he fell on his face and sustained a deviated nasal septum in service. The examiner provided a diagnosis of a traumatic deviated nasal septum. In a July 2017 medical opinion, another VA examiner reviewed the claims file and stated that while there is evidence of an acute injury in service, there is no credible evidence of a chronic deviated nasal septum condition in service or during a valid period after discharge. The examiner stated that a lag in treatment negates any continuity of care or symptomatology. The examiner concluded that the Veteran's deviated nasal septum was not incurred in, or caused by, service.

While the Board appreciates the examiner's opinion, it again was based on a lack of post service treatment records. The Veteran filed his initial claim for service connection for a deviated nasal septum in January 2010, just over a year after his discharge, and he adequately explained the lack of post service medical records. He also testified that he has had problems with his deviated nasal septum, including congestion and headaches, since service. Further, service treatment records clearly show that he injured his nose in February 2004 and was found to have an acquired deviated septum in May 2007. Even the June 2017 examiner noted that the Veteran has a traumatic deviated septum. Thus, resolving reasonable doubt in the Veteran's favor, the Board finds that his deviated nasal septum is related to active service. 38 U.S.C. § 5107(b). Service connection for a deviated nasal septum is warranted.

Residuals of epididymectomy

Service treatment records show that the Veteran underwent an epididymectomy and that he reported such history at his separation examination. A June 2017 VA examination report reflects that the Veteran provided a history, but that history is not included in the report. The Veteran
2004 and was found to have an acquired deviated septum in May 2007. Even the June 2017 examiner noted that the Veteran has a traumatic deviated septum. Thus, resolving reasonable doubt in the Veteran's favor, the Board finds that his deviated nasal septum is related to active service. 38 U.S.C. § 5107(b). Service connection for a deviated nasal septum is warranted.

Residuals of epididymectomy

Service treatment records show that the Veteran underwent an epididymectomy and that he reported such history at his separation examination. A June 2017 VA examination report reflects that the Veteran provided a history, but that history is not included in the report. The Veteran declined examination of the testes and epididymis; the examiner diagnosed epididymal cysts. In a July 2017 medical opinion, another VA examiner reviewed the claims file and stated that the Veteran's epididymal condition resolved in service and there is no credible evidence of chronic manifestations in service or during a valid period after discharge. The examiner stated that a lag in treatment negates any continuity of care or symptoms. The examiner concluded that the Veteran did not have any residuals of the in service epididymectomy.

The Veteran was afforded another VA examination in July 2021 at which time he reported that he injured his testicle/epididymis during boot camp, that he continued to have pain and that he was later diagnosed with an epidydimal cyst for which he had surgery to remove the left epididymis. He reported having pain in his scrotum ever since the surgery. He again declined examination of the testes and epididymis. The examiner provided a diagnosis of residual pain after left epididymectomy. In a separate medical opinion, the examiner concluded that the Veteran has residuals of left testicular pain since the in-service epididymectomy.

While the June 2017 examiner indicated that the Veteran did not have any residuals of the in-service epididymectomy, the report of that examination was incomplete, including the history section. On the other hand, the July 2021 examiner noted the Veteran's in-service history of injury and surgery, and of left testicular pain since the surgery. The Veteran filed his initial claim for service connection for residuals of an epididymectomy in January 2010, just over a year after his discharge, and he adequately explained the lack of post service medical records. He also testified that he has had problems since the in-service epididymectomy, including testicular tenderness. Resolving reasonable doubt in his favor, the Board finds that he has residuals of the in-service epididymectomy. 38 U.S.C. § 5107(b). Thus, service connection for the residuals of an epididymectomy is warranted.

Chronic headache disability

Service treatment records show that in February 2004 the Veteran slipped on ice and fell face-first onto the ground, suffering a laceration on the bridge of the nose. Examination revealed swelling of the nose and a small laceration. The diagnosis was rule out nasal fracture. Two weeks later, he complained of headaches for the past week that began after falling on his face. He was diagnosed with headaches and prescribed pain medication.

At an October 2012 VA examination, the Veteran reported that in February 2004 he slipped on ice and fell face-first, injuring his nose. He reported having swelling on the nose and headaches. He also reported that when he went to Korea in 2006, he had problems with panic attacks and headaches. He denied seeking any treatment for his headaches after discharge from service. The examiner provided a diagnosis of acute posttraumatic headache, resolved. The examiner stated that as there is no diagnosis of TBI, there are no residuals. The examiner stated that the Veteran did not have a concussion but had an acute posttraumatic headache which resolved as there is no evidence of further complaint of headaches. The examiner stated that the Veteran currently has tension headaches which are not due to service or related to an injury in service as there is no temporal relationship. 

Unlike the above claims, the Veteran did not file a claim for service connection for a headache disability until June 2012. However, he associated them with the fall that led to his deviated nasal septum, which the Board has found to be related to active service. As such, the record suggests that the headaches, as a manifestation of the deviated septum, likely continued intermittently since the in-service injury. As reported in service and at the October 2012 examination, his headaches began after the fall. While the Board appreciates the examiner's opinion, it was based on a lack of post service treatment records. However, only a continuity of symptoms is required to support a claim for service connection, and the Veteran adequately explained the lack of post service
, the Veteran did not file a claim for service connection for a headache disability until June 2012. However, he associated them with the fall that led to his deviated nasal septum, which the Board has found to be related to active service. As such, the record suggests that the headaches, as a manifestation of the deviated septum, likely continued intermittently since the in-service injury. As reported in service and at the October 2012 examination, his headaches began after the fall. While the Board appreciates the examiner's opinion, it was based on a lack of post service treatment records. However, only a continuity of symptoms is required to support a claim for service connection, and the Veteran adequately explained the lack of post service medical records. He also testified that he has had headaches since the in-service fall and that they were worsened by wearing Kevlar helmets and the sinus pressure due to his deviated nasal septum. Thus, resolving reasonable doubt in the Veteran's favor, the Board finds that his headache disability is related to active service. 38 U.S.C. § 5107(b). The Board, thus, concludes that service connection for a chronic headache disability on a direct basis is warranted. 

Psychiatric disorder

Service treatment records show that in July 2005 the Veteran reported a history of anxiety/panic attacks. August 2005 records show complaints of a panic attack and a diagnosis of an anxiety attack, with a note that he was started on Xanax two days ago. June 2006 records continue to show complaints of panic attacks and a note that they might be due to Ultram, which the Board observes is a prescription pain medication. A May 2007 record lists a diagnosis of anxiety disorder due to general medical condition, and a February 2008 record continues to carry the diagnosis.

At a June 2017 VA examination, the Veteran reported that he became anxious and panicky during service. The examiner noted that the service treatment records note problems with anxiety, including a diagnosis of anxiety. The examiner provided a diagnosis of generalized anxiety disorder. The examiner stated that the Veteran had difficulties with anxiety well before May 2007, noting panic attacks in 2006. The examiner noted that the June 2005 diagnosis of anxiety precluded the diagnosis of anxiety in May 2007. The examiner then concluded that the Veteran's anxiety in May 2007 did not cause his anxiety disorder. 

Initially, the Board notes that the AOJ requested a medical opinion on whether the Veteran's anxiety attacks were caused by the anxiety disorder diagnosed in May 2007 during service. The record is unclear as to why the AOJ phrased the question as such. However, that explains why the examiner provided the above opinion. In any event, the examiner's opinion does not properly address the issue of whether the Veteran's current psychiatric disorder is related to active service.

Given the above, service treatment records first note panic attacks in July 2005 which continued through June 2006 and were noted as due to an anxiety disorder in May 2007 and carried forward in February 2008. The Veteran filed an initial claim for service connection for anxiety attacks in January 2010, just over a year after his discharge, and he adequately explained the lack of post service medical records. He also testified that he developed panic attacks during service and has had anxiety and depression ever since. Thus, resolving reasonable doubt in the Veteran's favor, the Board finds that his psychiatric disorder is related to active service. 38 U.S.C. § 5107(b). Accordingly, the Board concludes that service connection for a generalized anxiety disorder is warranted. 

 

 

THERESA M. CATINO

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	J. W. Kim, 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.