Citation Nr: 1237127 Decision Date: 10/26/12 Archive Date: 11/09/12 DOCKET NO. 08-07 129 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Entitlement to service connection for varicose veins of the right lower extremity. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Jarrette A. Marley, Associate Counsel INTRODUCTION The appellant is a Veteran who served on active duty from October 1974 to July 1990. This matter is before the Board of Veterans' Appeals (Board) on appeal from a February 2006 rating decision by the Montgomery, Alabama Department of Veterans Affairs (VA) Regional Office (RO). In April 2012, a Travel Board hearing was held before the undersigned; a transcript of the Board hearing is associated with the claims file. The Veteran had also perfected an appeal as to service connection for laryngitis. A September 2011 rating decision granted service connection for laryngitis. As that decision represents a full grant of the benefit sought with regard to that issue, it will not be addressed further in this decision. At the April 2012 Travel Board hearing, the Veteran appeared to raise the issue of service connection for varicose veins of the left lower extremity. This matter has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. FINDING OF FACT It is reasonably shown that the Veteran has varicose veins of the right lower extremity that became manifest in service and have persisted since service. CONCLUSION OF LAW Service connection for varicose veins of the right lower extremity is warranted. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION A. Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The VCAA applies to the instant claim. Inasmuch as the benefit sought is being granted, there is no reason to belabor the impact of the VCAA on the matter; any notice defect or duty to assist omission is harmless. B. Legal Criteria, Factual Background, and Analysis Initially, the Board notes that all of the evidence in the Veteran's claims file and in Virtual VA (VA's electronic data storage system), with an emphasis on the evidence relevant to this appeal, has been reviewed. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claim. Service connection may be established for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). In order to establish service connection for a claimed disability, there must be medical, or in certain circumstances lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and an evaluation of its credibility and probative value. 38 C.F.R. § 3.303(a); Baldwin v. West, 13 Vet. App. 1 (1999). A disease may be service connected if shown to be of a chronic nature in service, or if not chronic, then seen in service with continuity of symptomatology demonstrated after discharge. 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488, 494-97 (1997). Disorders diagnosed after discharge may still be service connected if all the evidence, including pertinent service records, establishes that the disorder was incurred in service. 38 C.F.R. § 3.303(d); Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). A layperson is generally not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183, 186 (1997). However, lay evidence may be competent evidence to establish incurrence. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition (e.g., a broken leg), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. However, competent medical evidence is necessary where the determinative question is one requiring medical knowledge. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. Competent medical evidence may also include statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The Veteran's service treatment records (STRs) show that in October 1987 (at the United States Army Health Clinic in Erlangen, Germany), he complained of right lower leg pain after another person ran into him and their knees collided while playing football. The diagnosis was right leg muscle contusion. An undated Report of Medical History noted his complaint of pain in his lower legs when running. His remaining STRs contain no mention of varicose veins. A June 1990 lay statement from J.S.R. reported that he overheard a conversation between the appellant and another service member during which the appellant requested a bone scan be performed on his legs. Furthermore, the other service member told the appellant that he would get him an appointment for the bone scan, but that it would take a while. Springhill Medical Center private treatment records include June 2001 reports noting the Veteran's complaint of right leg pain and a "spot" on his leg. He also reported a chronic non-healing sore on his right inner leg. It was noted that the Veteran was involved in an accident in 1998 when he hit the brake in his vehicle suddenly and scraped his leg, and that it seemed like it had bothered him ever since. On physical examination, it was noted there was chronic venous insufficiency with hyperpigmentation bilaterally, worse on the right. There were large varicose veins, and a non-healing ulcer on the right inner leg above the ankle. The physician indicated that he wanted the Veteran to get a calf length stocking. Springhill Medical Center private treatment records also include May 2005 reports noting his complaint of a venous ulcer for several years. His illnesses were listed to include varicose veins. Physician's orders included compression stockings. In May 2005, the Veteran filed a claim for service connection for varicose veins with edema and pain of the right lower extremity. Springhill Medical Center private treatment records further include an October 2005 report noting the Veteran had a history of venous insufficiency, and that his right calf wound was well-healed. His complaints included pain and swelling of the right leg. In Veteran's August 2006 notice of disagreement, the Veteran reported that his varicose veins were visible during service. He further reported that he brought the varicose veins to the attention of medical personnel but he was advised to wait until the separation physical or when it gave him trouble. Attached medical treatise evidence indicated that deep venous obstruction resulting in varicose veins may be demonstrated by signs and symptoms of chronic venous insufficiency: edema, pain, pigmentation, and ulcerations. In July 2010 correspondence, the Veteran reported that he asked the chief medical officer during his service to have his legs inspected because he was having pain in them, and that his varicose veins could have been detected had he received a separation physical. At the April 2012 Travel Board hearing, the Veteran testified that during his last tour in Europe (from 1986 to 1990), he began having difficulties completing company and battalion runs. At some point during this tour, he became unable to complete the runs because of pain in his lower leg. He indicated he talked to a medical officer in an attempt to get his right leg inspected. He further reported that he did not receive a separation physical but that he did indicate (as noted above) pain in his lower leg on a report of medical history. He related that after service, when driving, his foot slipped off the gas pedal and he scratched his right leg where edema was located, and received treatment at the Springhill Medical Center. He further testified that he could see his varicose veins prior to a prescription of a compression hose. He also testified that the discoloration, edema, and protrusion of the skin he currently experienced existed during service and had worsened since. It is undisputed that the Veteran has varicose veins of the right lower extremity. They have been diagnosed, at least, since June 2001. However, they were not noted in the Veteran's STRs. Nonetheless, the Veteran has testified that he observed the varicose veins of his right lower extremity during his active service, and that it has persisted (and worsened) since his active service. He has also testified that he sought treatment for his legs during service, but was informed to wait until his separation examination, which he never received. However, his STRs reflect that he did complain of chronic pain in his lower legs when running in October 1987 and in another undated medical history report. The Board must consider the Veteran's own assertion that his current right lower extremity varicose veins are related to his period of active service. Lay witnesses are competent to opine as to some matters of diagnosis and etiology, and the Board must determine on a case-by-case basis whether a veteran's particular disability is the type of disability for which lay evidence is competent. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Kahana v. Shinseki, 24 Vet. App. 428, 433 n.4 (2011). Here, the Veteran's testimony that his right lower extremity varicose veins are a continuation of the same varicose veins that he had in service is testimony of a medical process of the type that has been determined to be within the competence of lay witnesses. Cf. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay witness is capable of diagnosing a broken leg); Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007) (lay testimony is competent to establish the presence of varicose veins); Falzone v. Brown, 8 Vet. App. 398, 403 (1995) (lay person competent to testify to pain and visible flatness of his feet). Thus, what is presented is a disability picture consisting of complaints of pain in the lower legs during active service, a diagnosis of varicose veins of the right lower extremity since 2001, and the Veteran's statements as to the existence of right lower extremity varicose veins since service. Accordingly, resolving any reasonable doubt as mandated by law (38 U.S.C.A. § 5107; 38 C.F.R. § 3.102), and under governing case law (see Barr, 21 Vet. App. at 308-09), the Board finds that the requisite nexus is shown, and that service connection for varicose veins of the right lower extremity is warranted. ORDER Service connection for varicose veins of the right lower extremity is granted. ____________________________________________ Michael J. Skaltsounis Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs