POSTTRAUMATIC STRESS DISORDER (PTSD)

CHRISTOPHER SEPPANEN · 2026 · Case ID: A26040813

MIXED

Summary

The Veteran, who served from July 1979 to June 1983 and September 1983 to October 2001, appeals the agency of original jurisdiction's (AOJ) decisions regarding several conditions. The Board granted service connection for an acquired psychiatric disability, finding the Veteran credible regarding in-service stressors, including a head injury from a beer mug incident and witnessing a severe burn injury. A VA examiner opined that the claimed condition was at least as likely as not incurred due to the in-service event. The Board also granted an initial 30 percent rating for headaches, finding the Veteran's symptoms, while frequent, did not meet the criteria for higher ratings due to a lack of completely prostrating and prolonged attacks with severe economic inadaptability. The case was remanded for further development and opinions on traumatic brain injury (TBI), neck disability, hypertension, and obstructive sleep apnea (OSA). For TBI, the remand is for an opinion on the link between the head injury and memory loss. For neck disability, the remand is due to an incomplete VA opinion that relied too heavily on the absence of post-service treatment. For hypertension, the remand is for an opinion on secondary service connection to sinusitis and headaches, as the initial opinion was insufficient. For OSA, the remand is for an opinion on aggravation by service-connected sinusitis, as the initial opinion lacked clarity. The claims for bilateral shoulder disability were also remanded for a new VA examination due to duty to assist errors, as the existing opinion was inadequate and did not fully address the Veteran's claims of in-service wear and tear and radiating neck pain.

Rationale

Credible in-service stressors documented (head injury, burn injury witness, fan belt accident).; VA examiner opined condition is at least as likely as not incurred in or caused by service.; Service connection for PTSD is warranted.

Special Benefit

NO SPECIAL BENEFIT

Docket No.

210628-168635

Full Decision Text

Citation Nr: A26040813
Decision Date: 04/30/26 Archive Date: 04/30/26

DOCKET NO. 210628-168635
DATE: April 30, 2026

ORDER

Entitlement to service connection for an acquired psychiatric disability is granted.

Entitlement to an initial 30 percent rating for service-connected headaches is granted.

REMANDED

Entitlement to service connection for traumatic brain injury is remanded.

Entitlement to service connection for a neck disability is remanded.

Entitlement to service connection for a right shoulder disability is remanded.

Entitlement to service connection for a left shoulder disability is remanded.

Entitlement to service connection for hypertension, to include as secondary to service-connected sinusitis and headaches, is remanded.

Entitlement to service connection for obstructive sleep apnea, to include as secondary to service-connected sinusitis, is remanded.

FINDINGS OF FACT

1. The Veteran's PTSD is related to an in-service stressor.

2. For the entire period on appeal, the Veteran's service-connected headaches more nearly approximate characteristic prostrating attacks occurring on an average of once a month over several months.

CONCLUSIONS OF LAW

1. The criteria for entitlement to service connection for an acquired psychiatric disability have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304.

2. The criteria for an initial 30 percent rating for headaches have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, §§ 4.1, 4.2, 4.3, 4.7, 4.15, 4.16, 4.124a, Diagnostic Code 8100.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran had active military service from July 1979 to June 1983, and from September 1983 to October 2001.

This case is being reviewed according to the appellate process set forth under the Veterans Appeals Improvement and Modernization Act of 2017 (hereinafter the "Appeals Modernization Act"). The Appeals Modernization Act became effective February 19, 2019.?

In October 2019 (bilateral shoulder, obstructive sleep apnea, headaches), November 2019 (neck disability, hypertension), and May 2021 (traumatic brain injury, psychiatric disability), the agency of original jurisdiction (AOJ) initially adjudicated his claim for the issues on appeal. In August 2020, the Veteran requested a higher-level review for his bilateral shoulder disability, obstructive sleep apnea, headaches, neck disability, and hypertension which was adjudicated in a January 2021 rating decision. In the June 2021 VA Form 10182, Decision Review Request: Board Appeal, the Veteran elected the Hearing docket. In February 2025, the Veteran testified at a hearing before the Board. The transcript of the hearing is of record. The Board may only consider the evidence of record at the time of the AOJ decision on appeal as well as any evidence submitted by the Veteran or his representative within 90 days following the Board hearing.

Service Connection

Generally, to establish service connection a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303 (d).

There are particular requirements for establishing PTSD in 38 C.F.R. § 3.304 (f), which take precedence over the general requirements for establishing service connection in 38 C.F.R. § 3.303. See Arzio v. Shinseki, 602 F.3d 1343, 1347 (Fed. Cir. 2010).

Establishment of service connection for PTSD requires: (1) medical evidence diagnosing PTSD; (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link between current
establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303 (d).

Establishment of service connection for PTSD requires: (1) medical evidence diagnosing PTSD; (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304 (f).

1. Entitlement to service connection for an acquired psychiatric disability is granted.

At the outset, the Board notes that in a March 2025 rating decision, the AOJ granted service connection for posttraumatic stress disorder (PTSD). However, as the grant was effective September 18, 2024, the Board finds that the service connection claim for acquired psychiatric disability is still pending before the Board.

Regarding the first element of service connection, a May 2021 VA examiner diagnosed the Veteran with PTSD. As such, the first element of service connection has been met.

Concerning the second element of service connection, the Board finds the Veteran credible as to his in-service stressors. First, the Veteran stated that he injured his head during Octoberfest when someone knocked him out with a beer mug in service. Second, in the February 2025 hearing, the Veteran attested that he witnessed someone in the shower getting third, second, and first-degree burns across the upper torso as the pipes malfunctioned and straight steam was covering the person. He stated that he saw the man's "skin just coming from his body." Third, in a May 2021 VA examination, the Veteran reported that his mental health symptoms began in 1982 when his hand was caught in a fanbelt of a vehicle and he almost lost his hand. Fourth, in a February 2025 third party statement, a major documented when the Veteran was worried about the mental state of a fellow marine only to find out later that the same marine committed suicide. See February 2025 Buddy/Lay Statement. Based on the foregoing, the second element of service connection has been met.

Regarding the third element of service connection, the Veteran was afforded a VA examination in May 2021 wherein the examiner opined that the claimed condition is at least as likely as not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that the fan belt accident during service was the initial traumatic event that triggered his PTSD diagnosis. He denied having any mental health symptoms prior to this accident and the records are consistent with this.

As there is persuasive medical evidence diagnosing PTSD, credible supporting evidence that the claimed in-service stressors actually occurred, and persuasive medical evidence of a link between the current symptomatology and the claimed in-service stressors, service connection is warranted.

Increased Ratings

Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38?C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38?U.S.C. §?1155; 38?C.F.R. §§?3.321, 4.1.

In evaluating the severity of a particular disability, it is essential to consider its history. 38?C.F.R. §?4.1; Peyton v. Derwinski, 1?Vet. App.?282 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7?Vet. App.?55, 58 (1994). Higher evaluations may be assigned for separate periods based on the facts found during the appeal period. Hart v. Nicholson, 21?Vet. App.?505, 509 (2007). See also Fenderson v. West, 12?Vet. App.?119, 126 (1999). This practice is known as staged ratings. Id.

Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation.
issue, the present level of disability is of primary importance. Francisco v. Brown, 7?Vet. App.?55, 58 (1994). Higher evaluations may be assigned for separate periods based on the facts found during the appeal period. Hart v. Nicholson, 21?Vet. App.?505, 509 (2007). See also Fenderson v. West, 12?Vet. App.?119, 126 (1999). This practice is known as staged ratings. Id.

2. Entitlement to an initial 30 percent rating for service-connected headaches is granted.

The Veteran's headaches are rated under Diagnostic Code 8100. Under Diagnostic Code 8100, a noncompensable rating is warranted for headaches with characteristic prostrating attacks averaging less than one in two months over the last several months. 38?C.F.R. §?4.124a, Diagnostic Code 8100. A 10 percent rating is warranted for headaches with prostrating attacks averaging one in two months over the last several months. A 30 percent rating is warranted for characteristic prostrating attacks occurring on an average once a month over the last several months. A 50 percent rating is warranted for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. A 50 percent rating is the highest schedular rating under Diagnostic Code 8100.

The phrase "characteristic prostrating attacks" is used in the criteria corresponding to 10 percent and 30 percent ratings under Diagnostic Code 8100 to describe the nature and severity of migraines, but it is not defined in the regulation. Pursuant to Dorland's Illustrated Medical Dictionary 1531 (32d ed. 2012), prostration is defined as "extreme exhaustion or powerlessness." Thus, the phrase "characteristic prostrating attacks" is understood to describe migraine attacks that typically produce extreme exhaustion or powerlessness.

The rating criteria for a 50 percent rating contains several undefined phrases. The descriptive phrase "very frequent" connotes a frequency at least greater than once a month, as is required by the rating criteria corresponding to a lesser 30 percent rating. Johnson v. Wilkie, 30 Vet. App. 245, 253 (2018). The phrase "completely prostrating" generally means that the migraine attack must render the veteran entirely powerless. Id. The completely prostrating attacks must also be "prolonged," which is defined as "to lengthen in time: extend duration: draw out: continue, protract." Id. (internal citation omitted). Lastly, the 50 percent rating criteria requires that the very frequent completely prostrating and prolonged attacks be "productive of severe economic inadaptability." Productive can be read as having either the meaning of "producing" or "capable of producing," and, with regard to severe economic inadaptability, nothing in Diagnostic Code 8100 requires that the claimant be completely unable to work in order to qualify for a 50 percent rating. Pierce v. Principi, 18?Vet. App.?440, 445-46 (2004).

As an initial matter, the Veteran filed a service connection claim for his headaches in March 2019. In an October 2019 rating decision, the AOJ granted service connection for his headaches.

A review of the medical records shows that in April 2018, October 2018, and February 2019 the Veteran denied having headaches. See May 2019 CAPRI. Then, in April 2019, the Veteran complained of having migraine headaches that were five out of ten in severity.

In a May 2019 VA examination, the Veteran endorsed having constant head pain, pulsating or throbbing head pain, pain on both sides of the head, and pain that worsens with physical activity. He also endorsed having nausea, and sensitivity to light and sound. He stated that during a typical head pain it would last less than one day and he would have head pain on both sides of his head. The examiner determined that he did not have characteristic prostrating attacks of migraine and/or non-migraine headache pain. The examiner also determined that he did not have very prostrating and prolonged attacks of migraine and/or non-migraine pain productive of severe economic inadaptability. He did not have other physical findings
May 2019 VA examination, the Veteran endorsed having constant head pain, pulsating or throbbing head pain, pain on both sides of the head, and pain that worsens with physical activity. He also endorsed having nausea, and sensitivity to light and sound. He stated that during a typical head pain it would last less than one day and he would have head pain on both sides of his head. The examiner determined that he did not have characteristic prostrating attacks of migraine and/or non-migraine headache pain. The examiner also determined that he did not have very prostrating and prolonged attacks of migraine and/or non-migraine pain productive of severe economic inadaptability. He did not have other physical findings, complications, conditions, signs, or symptoms related to his headaches. However, it was noted that the Veteran missed 10 days of work in the past six months due to his headaches.

In a June 2019 VA treatment record, he reported that he has headaches most days of the week and that he has gradually worsened frontal headache. See September 2019 CAPRI. However, by September 2019, his headaches decreased to once a month. In the February 2025 hearing, the Veteran attested that he has a least three headaches per week that would last about two to three hours. He testified that he does not take medication for his headaches.

The Board finds that the Veteran's headaches are consistent with a 30 percent disabling rating and no higher as the Veteran did not have headaches with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability.

In the February 2025 hearing, the Veteran claimed that he has headaches three times per week that would last about two to three hours. Moreover, the substantive and longitudinal history of his medical condition shows that the Veteran predominantly did not complain about his headaches. The Board finds that a person with completely prostrating migraine headaches would have sought treatment or at the minimum complained of his condition more. Instead, the Veteran rated his headache as five out of ten, which weighs against the finding of complete prostrating attack. Moreover, the treatment records show that in 2019 he only had one headache per month. As a result, after considering the frequency, severity, and duration of his headaches, the Board finds that the Veteran's migraine headaches consistent with no more nearly approximate the 30 percent rating criteria.

Thus, the Board concludes that the Veteran's headaches more nearly approximate a 30 percent rating as the evidence demonstrates persuasively that the Veteran does not have very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability.

REASONS FOR REMAND

1. Entitlement to service connection for traumatic brain injury is remanded.

At the outset, the Board notes that an April 2021 VA examiner diagnosed the Veteran with traumatic brain injury.

A review of the service treatment records (STRs) shows that he had a normal head condition with no endorsement of having a head injury in a November 1978 enlistment examination, April 1983 examination, and October 1985 examination. See May 2001 STR - Medical. However, in a September 1986 STR, it was noted that he was hit on the head by a beer mug. He was diagnosed with temporal parietal contusion. In an April 1988, August 1994, May 1995, November 2000, and July 2001 examinations he continued to have normal head condition with no endorsement of having a head injury.

In a September 2020 statement, the Veteran explained that in September 1986 he attended an outdoor event during Octoberfest when someone in the crowd hit the side of his head with a mug. The mug "exploded" and his knees buckled, and he walked away dazed. A buddy that witnessed the incident asked if he was okay and the Veteran 'snapped' and tried to assault the people in his path. The next morning, he did not recall the incident. This incident was reiterated by a third party statement. See September 2020 Buddy/Lay Statement.

The Veteran was afforded a VA examination in February 2021 wherein he endorsed having mild memory loss. The examiner opined that the claimed condition is less likely than not proximately due to or the result of his service-connected headaches. The examiner explained that the Veteran has headaches due to chronic frontal sinusitis and allergic rhinitis. Although he has an in-service isolated head injury, it is impossible to make a determination of the cause of headaches without speculation.

The Board finds that a remand is warranted as there is a pre-decisional duty to assist error. Specifically, the February 2021 VA examiner determined that it is impossible to make a determination of the cause of headaches without speculation. However, the examiner did not provide any rationale. Further, the Veteran claimed that he has mild memory loss as a result of his traumatic brain injury, but the examiner did not render a medical opinion as to the whether his memory loss is etiologically related to his traumatic brain injury. Based on the foregoing, a remand is warranted.

2. Entitlement to service connection for a neck disability is remanded.

At the outset, a November 2019 VA examiner diagnosed the Veteran with degenerative arthritis of the spine and intervertebral disc syndrome.

A review of the STRs shows that he had normal neck condition with no endorsement of having swollen or painful joints, arthritis, or bone or joint deformity in a November 1978, April 1983, October 1985, April 1988, May 1991, April 1993, August 1994, May 1995, April 1996, June 1999, November 2000, and July 2001 examinations. See May 2001 STR - Medical and May 2001 STR - Dental. However, in an October 1983 STR, he complained of having a stiff neck for four days. He was diagnosed with cervical musculoskeletal sprain. Besides the in service neck sprain, in a February 2025 hearing, the Veteran attested that he had neck pain since service as performing sit-ups with hands interlocked behind the head placed pressure on the neck.

He was afforded a VA examination in November 2019 wherein an examiner opined that the claimed condition is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that he had an in-service injury wherein the Veteran complained of neck pain with spasms in October 1983, and that the although the Veteran claimed that his neck pain has progressed since, the records show that he has not sought care for his neck pain until May 2019, which is about 30 years after service.

The Board finds that a remand is warranted because the November 2019 medical opinion is incomplete as the examiner's rationale is entirely based on the absence of chronicity of complaint or treatment for a neck condition since service. The absence of documented treatment in service or thereafter is not fatal to a service connection claim. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Based on the foregoing, the Board finds that a remand is warranted. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (where VA provides the Veteran with an examination in a service connection claim, the examination must be adequate).

3. Entitlement to service connection for a right shoulder disability is remanded.

4. Entitlement to service connection for a left shoulder disability is remanded.

At the outset, the Board notes that a June 2019 VA treatment record noted a diagnosis of shoulder pain, degenerative joint disease and that his shoulder pain limits his ability to lift. See September 2019 CAPRI. Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018) (United States Court of Appeals for the Federal Circuit has held that pain that causes functional impairment is a disability for VA compensation purposes even if there is no underlying diagnosis).

The STRs show that he had normal upper extremities with no endorsement of having painful or trick shoulder in November 1978, April 1983, April 1988, August 1994, May 1995, November 2000, and July 2001. See May 2001 STR - Medical. However, in a February 2020 Board hearing, the Veteran attested that he has bilateral shoulder disability due to the wear and tear that he sustained in service, such as doing pull-ups. He also stated that pain from his neck would radiate to his shoulders.

The Board finds that there is a pre-decisional duty to
for VA compensation purposes even if there is no underlying diagnosis).

The Board finds that there is a pre-decisional duty to assist error as a VA examination should have been afforded to the Veteran as he has a current diagnosis and a possible in service event. Based on the foregoing, the Board finds that a remand is warranted. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (where VA provides the Veteran with an examination in a service connection claim, the examination must be adequate).

5. Entitlement to service connection for hypertension, to include as secondary to service-connected sinusitis and headaches, is remanded.

In a February 2020 Board hearing, the Veteran stated that he had high blood pressure readings since service due to his headaches.

A review of the STRs show that he had normal vascular system with no endorsement of having a high blood pressure in November 1978, April 1983, January 1984, October 1985, April 1988, May 1991, April 1993, August 1994, May 1995, April 1996, June 1999, November 2000, and July 2001. See May 2001 STR - Medical and May 2001 STR - Dental. His blood pressure readings were as follows: 120/72 in November 1978; 120/60 in February 1983; 122/68 in April 1983; 100/62 in December 1983; 110/64 in June 1985; 128/72 in September 1986; 112/68 in April 1988; 104/84 in August 1994; 108/62 in November 2000; 136/86, 120/80, 134/90, 130/90, 130/84, 138/96, 138/92, 130/88, 146/100 in June 2001; and 124/84 in July 2001. In July 2001, he was noted to have borderline hypertension.

The post service treatment records show that he started to take antihypertensive medication in April 2016. See May 2019 CAPRI.

He was afforded a VA examination in November 2019. The Veteran claimed that the onset of his hypertension was in 2001 as he had headaches and high blood pressure readings due to neck pain and sinus issues. He was listed as having borderline hypertension in 2001, while on active duty. He reported that he was diagnosed with hypertension in 2016. The examiner opined that the claimed condition is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that the Veteran was seen for blood pressure issues while in service but was not diagnosed with hypertension until 2016. As there is no evidence of chronicity of care, a nexus has not been established.

The Board finds that a remand is warranted as the November 2019 medical opinion is incomplete. First, the Board notes that the absence of documented treatment in service or thereafter is not fatal to a service connection claim, and the absence of evidence in the service treatment records is an insufficient basis, by itself, for a negative opinion. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Second, the Veteran stated that his headaches and sinusitis elevated his blood pressure readings. As he is service connected for headaches and sinusitis, the examiner should have rendered a medical opinion regarding secondary service connection. As such, a remand is warranted.

6. Entitlement to service connection for obstructive sleep apnea, to include as secondary to service-connected sinusitis, is remanded.

The Board notes that an August 2019 VA examiner diagnosed the Veteran with obstructive sleep apnea.

Although the STRs are void of sleep-apnea related symptoms, in an October 2020 third party statement, his ex-wife wrote that during service she witnessed the Veteran "snore extremely loud" and that his breathing patterns would change when he
the Veteran stated that his headaches and sinusitis elevated his blood pressure readings. As he is service connected for headaches and sinusitis, the examiner should have rendered a medical opinion regarding secondary service connection. As such, a remand is warranted.

6. Entitlement to service connection for obstructive sleep apnea, to include as secondary to service-connected sinusitis, is remanded.

The Board notes that an August 2019 VA examiner diagnosed the Veteran with obstructive sleep apnea.

Although the STRs are void of sleep-apnea related symptoms, in an October 2020 third party statement, his ex-wife wrote that during service she witnessed the Veteran "snore extremely loud" and that his breathing patterns would change when he would sleep. See October 2020 Buddy/Lay Statement. He "often appear[ed] to stop breathing and then suddenly [made] a gasping sound as if he was struggling to obtain air." He also submitted another third party statement, wherein a gunnery sergeant witnessed the Veteran have loud and disruptive snoring at night. See February 2025 Buddy/Lay Statement. On multiple occasions, she observed the Veteran stop breathing momentarily during sleep, followed by gasping or choking sounds.

Notably, in an April 2011 VA examination, an examiner noted that there was doubt that the Veteran's awaking with morning frontal headaches is related to sinuses, and that these symptoms may be related to sleep apnea which the last sleep study did not confirm a diagnosis and as such a repeat study was suggested.

In an August 2019 VA examination, the Veteran stated that his symptoms began in 2001 when he had symptoms related to sinusitis. The examiner opined that the claimed condition is less likely than not proximately due to or the result of his service-connected sinusitis. The examiner explained that obstructive sleep apnea is characterized by recurrent obstruction of the pharyngeal airway during sleep with resultant hypoxia and sleep fragmentation. The pathogenesis of obstructive sleep apnea is due to the interaction between unfavorable anatomic upper airway susceptibility and sleep related changes in UA function. Soft tissue structures such as turbinate hypertrophy, and nasopharyngeal mass can be contributors to the condition. Nasal obstruction may also aggravate obstructive sleep apnea. It is not clear, and no literature was found, supporting obstructive sleep apnea being caused by sinusitis.

The Board finds that a remand is warranted as the August 2019 VA medical opinion is incomplete. The examiner did not opine whether his obstructive sleep apnea is at least as likely as not aggravated by his service-connected sinusitis. The examiner noted that nasal obstruction may aggravate obstructive sleep apnea. The examiner also stated that turbinated hypertrophy and nasopharyngeal mass can contribute to his sleep apnea. However, it is unclear whether obstructive sleep apnea is at least as likely as not aggravated by his service-connected sinusitis. As such, a remand is warranted.

The matters are REMANDED for the following action:

1. Obtain an addendum medical opinion with an appropriate examiner to determine the nature and etiology of his traumatic brain injury, neck disability, hypertension, and obstructive sleep apnea.

Traumatic brain injury - The examiner should provide an opinion as to whether it is at least as likely as not that his traumatic brain injury, to include claim of memory loss, is etiologically related to service.

Neck disability - The examiner should provide an opinion as to whether it is at least as likely as not that his neck disability is etiologically related to service.

In an October 1983 STR, he complained of having a stiff neck for four days. He was diagnosed with cervical musculoskeletal sprain. Besides the in service neck sprain, in a February 2025 hearing, the Veteran attested that he had neck pain since service as performing sit-ups with hands interlocked behind the head placed pressure on the neck.

Hypertension - The examiner should provide an opinion as to whether it is at least as likely as not that his hypertension is etiologically related to service.

The examiner must also
ay Statement.

Neck disability - The examiner should provide an opinion as to whether it is at least as likely as not that his neck disability is etiologically related to service.

Hypertension - The examiner should provide an opinion as to whether it is at least as likely as not that his hypertension is etiologically related to service.

The examiner must also opine as to whether it is at least as likely as not that the Veteran's hypertension was (a) caused by or (b) has been aggravated by his service-connected sinusitis and headaches.?

Obstructive sleep apnea - The examiner should provide an opinion as to whether it is at least as likely as not that his obstructive sleep apnea is etiologically related to service.

The examiner must also opine as to whether it is at least as likely as not that the Veteran's sleep apnea was (a) caused by or (b) has been aggravated by his service-connected sinusitis.?

The examiner should note that an August 2019 VA examiner stated that soft tissue structures such as turbinate hypertrophy, and nasopharyngeal mass can be contributors to the condition. Further, nasal obstruction may also aggravate obstructive sleep apnea.

2. Schedule the Veteran for an examination with an appropriate examiner to determine the nature and etiology of his bilateral shoulder disability. The Veteran's file must be reviewed by the examiner.

Bilateral shoulder disability - The examiner should provide an opinion as to whether it is at least as likely as not that his bilateral shoulder disability is etiologically related to service.

The examiner should consider that in a February 2020 Board hearing, the Veteran attested that he has bilateral shoulder disability due to the wear and tear that he sustained in service, such as doing pull-ups. He also stated that pain from his neck would radiate to his shoulders.

In providing the requested opinion, the examiner must specifically consider and discuss the Veteran's description of his in-service injury and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of his current disability, this should be noted.

The examiner is informed that a positive opinion indicating a nexus to service does not require certainty. Rather, if the weight of the evidence is in approximate balance for and against a nexus to service, the examiner should make a determination favorable to the Veteran. The examiner is also reminded that a lack of continuity of care is an insufficient rationale for finding that a given diagnosis is unrelated to service; rather, the examiner must consider the Veteran's reports of continuity of symptomatology, whether such symptoms were reported or not, either during service or thereafter.

A detailed rationale for the opinion must be provided. If the examiner is unable to offer the requested opinion, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge.?

Christopher Seppanen

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board P. Noh

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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