HYPERTENSION

BETHANY L. BUCK · 2026 · Case ID: A26040417

MIXED

Summary

The veteran, who served during multiple periods including June 1999 to June 2003, September 2007 to October 2008, and January 2010 to February 2011, appeals the February 2021 rating decision. The veteran sought service connection for hypertension, left knee patellofemoral syndrome, right knee patellofemoral syndrome, and degenerative disc disease of the lumbar spine. The Board granted service connection for hypertension, finding it secondary to service-connected PTSD based on a private medical opinion that linked the two conditions as at least as likely as not. The Board also granted service connection for left and right knee patellofemoral syndrome, noting that the RO had previously granted these conditions secondary to hip disabilities, and the Board's grant aimed to preserve the possibility of an earlier effective date. The claim for lumbar spine degenerative disc disease was remanded due to inadequate VA medical opinions. The examiners' opinions were found conclusory or based solely on the absence of service treatment records, failing to adequately address the veteran's lay statements about the onset and continuity of his back condition. The Board instructed the VA to obtain an addendum opinion addressing the veteran's specific contentions and the adequacy of prior opinions.

Rationale

Private medical opinion found hypertension at least as likely as not secondary to PTSD.; Medical literature supports connection between PTSD and hypertension.; Presumption of soundness applies as hypertension did not clearly pre-exist service.

Special Benefit

NO SPECIAL BENEFIT

Docket No.

210224-141938

Full Decision Text

Citation Nr: A26040417
Decision Date: 04/29/26 Archive Date: 04/29/26

DOCKET NO. 210224-141938
DATE: April 29, 2026

ORDER

Entitlement to service connection for hypertension is granted.

Entitlement to service connection for left knee patellofemoral syndrome (left knee disability) is granted.

Entitlement to service connection for right knee patellofemoral syndrome (right knee disability) is granted.

REMANDED

Entitlement to service connection for degenerative disc disease of the lumbar spine (lumbar spine disability) is remanded.

FINDINGS OF FACT

1. The most probative evidence of record shows that the Veteran's hypertension was caused or aggravated by his service-connected posttraumatic stress disorder (PTSD).

2. The evidence is at least evenly balanced as to whether the Veteran's bilateral knee disabilities are caused by his service-connected bilateral hip disabilities and the claim being granted was filed on July 23, 2020, and was continuously pursued.

CONCLUSIONS OF LAW

1. The criteria for entitlement to service connection for hypertension have been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.306, 3.310.

2. The criteria for entitlement to service connection for left knee patellofemoral syndrome (left knee disability), on a direct basis, have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303,

3. The criteria for entitlement to service connection for right knee patellofemoral syndrome (right knee disability), on a direct basis, have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303,

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served honorably on multiple periods of active duty, to include from June 1999 to June 2003, September 2007 to October 2008, and from January 2010 to February 2011.

These matters come before the Board of Veterans' Appeals (Board) on appeal from a February 2021 rating decision of a Regional Office (RO) of the Department of Veterans Affairs (VA).

In the February 24, 2021 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Hearing docket. A Board hearing was held on November 19, 2024 by the undersigned Veterans Law Judge.

Therefore, the Board may only consider the evidence of record at the time of the February 2021 agency of original jurisdiction (AOJ) decision on appeal, as well as any evidence submitted by the Veteran or representative at the hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a). If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the Board hearing, or (2) more than 90 days following the hearing, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.302(a), 20.801.

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 claims, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

However, because the Board is remanding the claim of entitlement to service connection for degenerative disc disease of the lumbar spine, any evidence the Board could not consider will be considered by the AOJ in the adjudication of that claim. 38 C.F.R. § 3.103(c)(2)(ii).

Moreover, as discussed below, the claims for entitlement to service connection a left knee disability and a right knee disability involve the issue of concurrent elections, which resulted in grants of entitlement to service connection for left and right knee patellofemoral syndrome prior to this instant decision. Nevertheless, the Board will consider the claims of entitlement to service connection and whether an earlier effective date is warranted based on an earlier claim or alternative theory of entitlement. See Concepcion-Maldonado, 38 Vet. App. 294, 302 (2025) ("mootness is a case-specific inquiry requiring the [Board] to reckon with the individual circumstances of the appeal and the implications for appellant's ability to obtain full relief"); Stender v. Wilkie, No. 19-0068, 2020 U.S. App. Vet. Claims LEXIS 520, *5-*7 (Mar. 27, 2020) (mem dec) (Falvey, J.) (the Board erred in granting service connection based on the Camp Lejeune Contaminated Water (CLCW) presumption without considering other theories of entitlement that could warrant an earlier effective date because of the effective date of the CLCW presumption); Bethea v. Derwinski, 2 Vet. App. 252, 254 (1992) (single judge decisions may be relied upon for any persuasiveness or reasoning they contain).

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. §§ 1130, 5107; 38 C.F.R. § 3.303. Generally, service connection requires three elements: (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).

Service connection may be established on a secondary basis for disability which is proximately due to or the result of service-connected disease or injury. 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) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Where a service-connected disability aggravates a nonservice-connected condition, a veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Id.

In adjudicating such claims, reasonable doubt that exists because of an approximate balance of positive and negative evidence concerning any point will be resolved in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102.

1. Entitlement to service connection for hypertension is granted.

The Veteran contends that he was diagnosed with hypertension during his Reserve service (around 2005), and that it has persisted to the present date. See February 2018 VA 21-4138 Statement in Support of Claim. The Veteran also asserts that his hypertension was aggravated by his deployment and active service in Iraq. See April 2018 VA 21-4138 Statement in Support of Claim.

The medical evidence of record establishes that the Veteran has a current disability of hypertension. See August 2016 VA examination.

During the August 2016 VA examination, the examiner opined that the Veteran's hypertension existed prior to service and was not aggravated beyond its natural progression by an in-service injury, event, or illness. The examiner reasoned that the Veteran's "blood pressure trend does not support aggravation or aggravation beyond its natural progression." The Board finds that this opinion is conclusory because it includes no rationale to support its findings. As such, it is entitled to little probative weight as to the issue of nexus between the Veteran's current hypertension and his active service.

An additional VA opinion was obtained in January 2020. The VA examiner provided an opinion addressing direct service connection, finding that the Veteran's hypertension was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The VA examiner reasoned, "[the] Veteran's claim statement places onset of
natural progression by an in-service injury, event, or illness. The examiner reasoned that the Veteran's "blood pressure trend does not support aggravation or aggravation beyond its natural progression." The Board finds that this opinion is conclusory because it includes no rationale to support its findings. As such, it is entitled to little probative weight as to the issue of nexus between the Veteran's current hypertension and his active service.

An additional VA opinion was obtained in January 2020. The VA examiner provided an opinion addressing direct service connection, finding that the Veteran's hypertension was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The VA examiner reasoned, "[the] Veteran's claim statement places onset of hypertension around 2005. Veteran was not in active service at this time. Claim statement September 5, 2017, also indicates he was 'cleared for active service' in 2009 with hypertension, indicating condition pre-existed service. Medical records do not indicate onset of hypertension during service. June 4, 2011, retention exam negative for hypertension. Medical condition of hypertension does not appear to have been incurred by active service and it is less likely than not caused by the Southwest Asia service during service."

The Board notes, however, that hypertension was not noted on the Veteran's June 1999 entrance examination. The presumption of soundness applies only when a disease or injury not noted upon entry to service manifests in service, and a question arises as to whether it preexisted service. Gilbert v. Shinseki, 26 Vet. App. 48, 55 (2012), aff'd 749 F.3d 1370 (Fed. Cir. 2014). In this case, there is a question as to whether the Veteran's hypertension preexisted his military service.

As mentioned above, the Veteran has had multiple periods of active duty service, as well as periods of Reserve service. The Veteran's June 1999 enlistment examination does not contain any notation regarding hypertension. However, the enlistment examinations for his other periods of active duty service appear to be unavailable. The Veteran had a Reserve retention examination in June 2011, which is absent of any notations of defects, infirmities, or disorders related to the Veteran's hypertension. Therefore, with respect to hypertension, the Board finds that the presumption of soundness attaches. See 38 C.F.R. § 3.304(b); see also Quirin v. Shinseki, 22 Vet. App. 390, n.5 (2009) (citing Lee v. Brown, 10 Vet. App. 336, 339 (1997) (holding that the presumption of soundness applies even when the record of a veteran's entrance examination has been lost or destroyed while in VA custody)). Because the presumption of soundness attaches with respect to this disability, there must be clear and unmistakable evidence that the disorder both pre-existed service and was not aggravated in service. Id.; see also Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004).

The most competent and credible evidence of record illustrates that the Veteran's hypertension did not clearly and unmistakably preexist service. Specifically, there is a competent medical opinion noting that it is possible the Veteran's hypertension did not preexist service. Accordingly, there is not clear and unmistakable evidence that the Veteran's hypertension preexisted his active service. Therefore, the presumption of soundness has not been rebutted. When VA fails to carry its burden as to either preexistence or lack of aggravation, whether and to what extent the Veteran is entitled to compensation for the injury would be determined upon the assumption that the injury was incurred during service. It does not necessarily follow, however, that an unrebutted presumption of soundness will lead to service connection for the disease or injury. The Veteran must still demonstrate a current disability and a nexus between the current disability and the injury or disease in service. Horn v. Shinseki, 25 Vet. App. 231, 233 (2012).

In this regard, the Veteran submitted an opinion in July 2020 completed by his private treatment provider, R.L., which raised an additional theory of service connection; secondary service connection. The private treatment provider indicated that he reviewed the Veteran's medical history, and his military treatment records from June 1999 to June 2011. The private treatment provider indicated that the Veteran denies a diagnosis of hypertension prior to joining the military, and that his blood pressure is approximately 130/90 with medication, and higher without. The private treatment provider indicated he would discuss the Veteran's diagnosis of hypertension and how this disability correlates with his service-connected posttraumatic stress disorder (PTSD). Regarding etiology of the Veteran's hypertension disability, the private treatment provider stated, "[a]fter reviewing the medical literature and from my professional opinion, the development and aggravation of hypertension can be multifactorial, but a common comorbidity of hypertension is mental health disorders, specifically PTSD and depression. Increases in blood pressure related to stress can be dramatic. According to the Mayo Clinic, 'frequent, temporary spikes in blood pressure can damage your blood vessels, heart, and kidneys in a way similar to long-term high blood pressure.'" The private treatment provider cited several medical journal studies which all provided support for the proposition that PTSD was associated with increased risk for hypertension, and that hypertension was more prevalent in people who had PTSD. As such, the private treatment provider found that "it is at least as likely as not that the Veteran's hypertension is secondary to and exacerbated by his service-connected PTSD. The medical literature supports the connection between these conditions, and the Veteran has an increased risk of development of hypertension due to his service-connected disability."

Reviewing the evidence of record, the Board finds that all elements of secondary service connection for the Veteran's claim have been met. As noted above, the Veteran has a current disability of hypertension. Additionally, the Veteran's service-connected disabilities include PTSD. Therefore, the first two elements of secondary service connection have been established. Regarding nexus, the Veteran submitted the July 2020 private medical opinion addressing the etiology of his hypertension. The private medical provider concluded that the Veteran's hypertension was at least as likely as not due to or aggravated by the Veteran's service-connected PTSD. The examiner discussed several medical studies linking the Veteran's diagnosed hypertension to PTSD. As the opinion includes an adequate rationale and references pertinent medical literature, the Board will afford it substantial evidentiary weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2008).

Further, there is no other probative evidence against the claim. Accordingly, the Board finds that entitlement to service connection for hypertension, as secondary to service-connected PTSD, is warranted, and the Veteran's claim is granted.

2. Entitlement to service connection for left knee patellofemoral syndrome is granted.

3. Entitlement to service connection for right knee patellofemoral syndrome is granted.

The Veteran filed his initial claim for entitlement to service connection for bilateral knee disabilities on December 20, 2013. This claim was continuously pursued, to include withdrawn from the legacy appeals system and transferred into the Appeals Modernization Act (AMA) system via RAMP, until February 25, 2019, upon the issuance of a RAMP rating decision.

Following the RAMP rating decision, the Veteran did not file for any of the available review options within one year of issuance of the decision. As such, the February 2019 RAMP rating decision became final.

The Veteran then filed his current claim (VA 20-0995 Supplemental Claim) for bilateral knee disabilities on July 23, 2020. In a July 2020 rating decision, the RO declined to readjudicate the claims, finding no new and relevant evidence had been received. The Veteran then filed an additional Supplemental Claim on August 5, 2020. In An August 21, 2020, rating decision the RO found that new and relevant evidence had been received in support of the Veteran's claims but denied the claims on the merits. The Veteran then filed an additional supplemental claim in December 2020, with a rating decision issued on February 12, 2021, which is the rating decision on appeal.

From the February 2021 rating decision, two appeal streams emerged related to the claim of entitlement to service connection for bilateral knee disabilities.

The first appeal stream stems from the Veteran's February 2021 VA Form 10182. By letter dated March 18, 2021, the Board notified the Veteran that his appeal has been placed on the Hearing docket. At this point, 38 C.F.R. § 3.2500(b)
evidence had been received in support of the Veteran's claims but denied the claims on the merits. The Veteran then filed an additional supplemental claim in December 2020, with a rating decision issued on February 12, 2021, which is the rating decision on appeal.

From the February 2021 rating decision, two appeal streams emerged related to the claim of entitlement to service connection for bilateral knee disabilities.

The first appeal stream stems from the Veteran's February 2021 VA Form 10182. By letter dated March 18, 2021, the Board notified the Veteran that his appeal has been placed on the Hearing docket. At this point, 38 C.F.R. § 3.2500(b) applies, which states, "With regard to the adjudication of a claim or an issue as defined in § 3.151(c), a claimant who has filed for review under one of the options available under paragraph (a) of this section may not, while that review is pending final adjudication, file for review under a different available option." 38 C.F.R. § 3.2500(a) includes supplemental claims.

The second appeal stream began in May 2022, when the Veteran filed a supplemental claim, VA Form 20-0995, Supplemental Claim, for his previously denied service connection claim for bilateral knee disabilities. Pursuant to 38 C.F.R. § 3.2500(b), this was an improper concurrent election, with the Veteran filing for review under a different available option, the supplemental claim, while the Board review was pending final adjudication.

In an August 2022 rating decision, the RO, seemingly unaware of the docketed Board appeal, granted service connection for left and right knee patellofemoral syndrome, secondary to service-connected left and right hip trochanteric pain syndromes, on a causation basis. This grant necessarily includes finding that all of the criteria for secondary service connection have been met. Under the AMA, the Board is bound by favorable findings made by the RO. 38 C.F.R. § 3.104(c).

Although entitlement to service connection for bilateral knee disabilities have been granted by the RO, the Board must nevertheless consider other theories of entitlement that could warrant an earlier effective date. Cf. Stender v. Wilkie, No. 19-0068, 2020 U.S. App. Vet. Claims LEXIS 520, *5-*7 (Mar. 27, 2020) (mem dec) (Falvey, J.) (the Board erred in granting service connection based on the Camp Lejeune Contaminated Water (CLCW) presumption without considering other theories of entitlement that could warrant an earlier effective date because of the effective date of the CLCW presumption); Bethea v. Derwinski, 2 Vet. App. 252, 254 (1992) (single judge decisions may be relied upon for any persuasiveness or reasoning they contain).

Here, the RO assigned the effective date of October 7, 2021, for the Veteran's bilateral knee disabilities based on the date VA received the Veteran's intent to file a claim form, prior to the completed supplemental claim on May 3, 2022. The effective date was not based on a specific theory of entitlement, either direct or secondary service connection, but the procedural history of the second appeal stream. By the RO's account, the February 2021 rating decision on appeal became final and was reopened by the May 2022 supplemental claim. See 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.156(b), 20.1103. However, the Veteran had continuously pursued the July 2020 denial of entitlement to service connection for bilateral knee disabilities, see 38 C.F.R. § 3.2500(c), and the July 2020 rating decision remained pending before the Board until this instant decision. Accordingly, the Board is granting service connection for bilateral knee disabilities even though the AOJ has already granted service connection for this disability, because in implementing this grant of service connection the AOJ should consider July 23, 2020, the date of claim, as the relevant date of claim. Dismissal based on the prior, AOJ grant of service connection is therefore not appropriate because the Board's grant of service connection for the same disability could well result in an earlier effective date upon implementation of the decision for the above reasons. Johnson v. Collins, 38 Vet. App. 151, 158 (2025) (quoting Bailey v. Wilkie, 33 Vet. App. 188, 203-04 (2021) (remanding to "preserve[ ] the possibility of
J has already granted service connection for this disability, because in implementing this grant of service connection the AOJ should consider July 23, 2020, the date of claim, as the relevant date of claim. Dismissal based on the prior, AOJ grant of service connection is therefore not appropriate because the Board's grant of service connection for the same disability could well result in an earlier effective date upon implementation of the decision for the above reasons. Johnson v. Collins, 38 Vet. App. 151, 158 (2025) (quoting Bailey v. Wilkie, 33 Vet. App. 188, 203-04 (2021) (remanding to "preserve[ ] the possibility of an earlier effective date and safeguard[ ] against any preclusive effect of the later RO decision"); Warren v. McDonald, 28 Vet. App. 214, 221 (2016) (remanding because the later grant by the RO "was only able to grant service connection" effective the date of the second claim)).

For the above reasons, the evidence is at least evenly balanced as to whether the Veteran's bilateral knee disabilities are related to his service-connected bilateral hip disabilities. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, the July 23, 2020, claim for entitlement to service connection must be granted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

REASONS FOR REMAND

1. Entitlement to service connection for degenerative disc disease of the lumbar spine (lumbar spine disability) is remanded.

The Veteran asserts that he has a lumbar spine disability due to service. The Veteran asserts that his lumbar spine condition began during his time in service and has been continuous up until the present. The Veteran contends that wearing body armor and gear that was 60 pounds or more daily during his active service put immense strain on his lumbar spine, resulting in his current degenerative disc disease.

In an August 2016 VA back examination, the Veteran was diagnosed with degenerative disc disease of the lumbar spine. On medical history, the examiner noted the Veteran's report that his condition began during service as a result of wearing body armor while training. The Veteran endorsed daily low back pain, as well as functional impairment with bending. The August 2016 VA examiner also found that the Veteran's lumbar degenerative disc disease was less likely than not related to a specific exposure event during the Veteran's service in Southwest Asia. The VA examiner based this opinion upon the lack of documented treatment for a lumbar spine disability in the Veteran's service treatment records (STRs).

The Veteran underwent an additional VA back examination in February 2019. The VA examiner diagnosed the Veteran with lumbosacral strain. During the examination, the Veteran again reported that his back pain began during his active service, as a result of doing PT and training with body armor, training for hand-to-hand combat, falling, and doing the fireman carry. The Veteran reported that since that time, he has had problems with his back, including pain. Regarding etiology of the Veteran's lumbar spine disability, the February 2019 VA examiner opined that the Veteran's claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The VA examiner reasoned, "[a]lthough the Veteran presents with lumbar strain, the Veteran does not have any objective evidence of lumbar degenerative disc disease and there are no STRs to support treatment of a back condition during service."

Most recently, the Veteran underwent a September 2019 back VA examination. The VA examiner opined regarding the etiology of the Veteran's lumbar spine disability, finding that it is less likely than not related to a specific exposure event experienced by the Veteran during service in Southwest Asia. The examiner reasoned that "[b]ack pain/strains are common conditions due to injuries in the military due to the required physical activities. Injury due to wear and tear and acute injuries are common."

The Board observes that none of the VA examiners of record address the Veteran's contentions that his back pain began in service and has continued since, due to the intense physical activity and training that the Veteran underwent throughout his active service. Hence the Board finds these medical opinions on which the RO relied to deny this Veteran's claim inadequate. Further, the VA examiners' opinions are inadequate because they are based solely on the absence of documentary evidence within the Veteran's STRs. See Jones v. Shinseki, 23 Vet. App. 382, 390 (2010). An examiner may not base a negative opinion solely on the lack of objective evidence in the Veteran's STRs. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). The Board notes that lack of documentation of a disability is not, by itself, dispositive when establishing direct service connection. A medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record. See Stefl v. Nicholson, 21 Vet. App. 120, 124-125 (2007).

Thus, the AOJ's failure to obtain an adequate direct service connection opinion was a pre-decisional duty to assist error warranting remand under the AMA and implementing regulations. 38 C.F.R. § 20.802(a).

The matters are REMANDED for the following action:

1. Obtain an addendum opinion to determine the nature and etiology of the Veteran's lumbar spine disability. The electronic claims file must be made accessible to the examiner for review in conjunction with the examinations. The VA examiner must offer an opinion as to the following:

(a.) The examiner should opine as to whether it is at least as likely as not that his lumbar spine disability had its onset in service or is otherwise etiologically related to the Veteran's active service, specifically addressing the Veteran's lay statements that his lumbar spine symptoms started during his active service, and that he fell several times on his back, wore 75 to 80 pounds of gear including body armor and combat vest in training, while completing intense physical exercises. See VBMS, document labeled VA 21-4138 Statement in Support of Claim, receipt date 02/28/2018; April 25, 2018, September 6, 2018.

(b.) The examiner should also address the September 2019 VA examiner's statement that "b]ack pain/strains are common conditions due to injuries in the military due to the required physical activities. Injury due to wear and tear and acute injuries are common." See VBMS, document labeled C&P Exam, receipt date September 12, 2019.

(c.) The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the likelihood is at least approximately balanced or nearly equal, if not higher. Note that the lack of documented treatment in service, or a long period after, while probative, cannot serve as the sole basis for a negative finding. The Veteran's lay contentions must be considered and weighed in making the determination.

Bethany L. Buck

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board R. M. Lowman, 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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