Citation Nr: 1317134 Decision Date: 05/24/13 Archive Date: 05/31/13 DOCKET NO. 12-16 269 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Buffalo, New York THE ISSUES 1. Entitlement to service connection for varicose veins, to include as secondary to a service-connected disability. 2. Entitlement to service connection for stasis dermatitis, to include as secondary to a service-connected disability. 3. Entitlement to service connection for peripheral neuropathy, to include as secondary to a service-connected disability. REPRESENTATION Appellant represented by: New York State Division of Veterans' Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A. Michel, Associate Counsel INTRODUCTION The Veteran had active service from August 1972 to August 1975. This case comes before the Board of Veterans' Appeals (Board) on appeal from a March 2011 rating decision of the Regional Office (RO) in Buffalo, New York that in pertinent part denied entitlement to service connection for the disabilities on appeal. In January 2013, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. A copy of the transcript is of record. At the hearing, the Veteran provided additional evidence with a waiver of RO review. The waiver and the evidence have been associated with the claims file. The Board has not only reviewed the Veteran's physical claims files but also the Veteran's file on the "Virtual VA" system to ensure a total review of the evidence. FINDINGS OF FACT 1. Varicose veins are proximately due to the service-connected left knee disability. 2. Stasis dermatitis is proximately due to the service-connected varicose veins. 3. Peripheral neuropathy is proximately due to the service-connected left knee disability. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for varicose veins have been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). 2. The criteria for entitlement to service connection for stasis dermatitis have been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). 3. The criteria for entitlement to service connection for peripheral neuropathy have been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In general, service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a) (2012). In order to prevail on the issue of service connection, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247, 253 (1999). Secondary service connection may be granted for a disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). Regarding secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus between the service-connected disability and the claimed disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Secondary service connection also applies to aggravation of a nonservice-connected disability by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). The Board notes that VA amended its regulation pertaining to secondary service connection, effective from October 10, 2006. See 71 Fed. Reg. 52,744 (2006) (codified at 38 C.F.R. § 3.310). However, the amended regulation does not apply in this case. The Veteran asserts, and testified before the undersigned, that he is entitled to service connection for varicose veins, stasis dermatitis, and peripheral neuropathy, resulting from his service-connected disabilities. At the outset, the Board notes that VA medical records establish current diagnoses of varicose veins, stasis dermatitis, and peripheral neuropathy. In addition, as stated above, the Veteran is service-connected for a left knee disability and a back disability. Thus, these elements of the secondary service connection claim have been satisfied. The question for consideration is whether his current varicose veins, stasis dermatitis, and peripheral neuropathy are related to such service-connected disabilities. In September 2009 and January 2012 Ms. N.A., M.S.N., submitted correspondence in which she stated that a review of the record indicated that the Veteran was service-connected at 20 percent for rheumatoid arthritis. (The Board notes at this point that it is clear from a review of the evidence that Ms. N.A. is referring to the Veteran's service-connected left knee disability.) She also noted that he was service-connected at 10 percent for degenerative arthritis of the spine and 0 percent for limited motion of the wrist. Ms. N.A. noted that on examination the Veteran showed chronic venous stasis swelling of the left lower leg with prominent varicosities and peau d'orange skin. She mentioned an article in which it discussed how varicosities can be caused when fluid in the joints increases and additional pressure is placed on the circulatory system causing varicosities. The Veteran's medical records revealed stasis dermatitis and swelling of his left lower leg below his affected left knee which remained chronically effused and requiring intermittent joint aspiration. Ms. N.A. also noted that the Veteran was referred to physical therapy in August 2009 for his exacerbated back pain with radicular symptoms. The Veteran reported a sensory loss down the left lateral thigh and a decrease in lorsdosis. A 2009 electromyography (EMG) test revealed generalized peripheral neuropathy. Ms. N.A. stated that one cause of acquired neuropathy is herniated disks in the back for which the Veteran was currently receiving physical therapy, and he was service-connected for degenerative arthritis of the spine. She noted that the most common neurological manifestation of rheumatoid arthritis was a mild, primarily sensory peripheral neuropathy, usual more marked in the lower extremities. She found that the Veteran exhibited these symptoms which were confirmed by EMG. She opined that it was more likely than not that the neuropathic/radicular symptoms he experienced, and the EMG evidence of this, was related to his service-connected disability of rheumatoid arthritis and degenerative arthritis of the spine. She concluded that, in pertinent part, stasis dermatitis, varicosities, and neuropathy had a casual relationship from his service-connected conditions. In the January 2012 report, Ms. N.A. also stated that although there was no mention in his active duty service records regarding the stasis dermatitis changes and swelling, it was easy to draw correlation between chronic swelling of the left knee and subsequent posterior swelling immediately below the knee and of the lower left leg. She stated that chronic swelling can lead to stasis dermatitis changes. The Veteran was afforded a VA arteries and veins examination in April 2010 in which he reported that varicose veins started to develop in 1974 on the left leg just around the left knee joint and became progressively worse with time. He reported that stasis dermatitis developed in the early 1980s with considerable itching and pain in the left lower leg. The examiner noted that there was considerable pigmentation in the left lower half of the left leg and pitting edema. Physical examination on the left leg, one inch below and medial to the knee joint, showed a large varicose vein which was visible as well as palpable; there were small, multiple varicose veins in the left leg below the knee all the way down to the ankle and the leg. There was stasis and hyperpigmentation in the lower half of the left leg, but there was no eczema. The diagnoses were varicose veins and stasis dermatitis. The examiner opined that it was as likely as not that the varicose vein condition was service related; the stasis dermatitis was secondary to the varicose vein condition. The Veteran was afforded a VA examination for the peripheral nerves in April 2010 in which it was noted that he injured his back while in the military. He reported numbness, tingling, and burning in his legs bilaterally with weakness, unsteadiness, burning in his feet, and decreased sensation. The examiner noted that the EMG/nerve conduction study performed in April 2009 showed generalized neuropathy of a moderate degree. The diagnosis was generalized neuropathy. The examiner stated that the Veteran had a history of service connection for rheumatoid arthritis (left knee disability) and rheumatoid arthritis was a known cause of generalized peripheral neuropathy; therefore, the examiner opined that it was at least as likely as not that his peripheral neuropathy was related to his military service. The Veteran was also afforded a VA dermatology examination in April 2010 in which the examiner was asked to opine as to whether the stasis dermatitis was a direct result of the Veteran's service-connected disabilities. The examiner opined that stasis dermatitis and varicosities were not related or had a causal relationship to rheumatoid arthritis or degenerative arthritis of the spine; "there is a connection between should read rheumatoid arthritis and the development of a vasculitic process, although the Veteran does not have any current symptoms of a vasculitic process." The examiner stated that the physical examination findings were consistent with stasis dermatitis and chronic venous insufficiency with varicosities present; therefore, the diagnosis of stasis dermatitis and varicosities were not caused by or a result of his service-connected disabilities. The Board acknowledges the opinion submitted by the April 2010 VA dermatology examiner that stasis dermatitis and varicosities were not caused by or a result of the Veteran's service-connected disabilities. Greater weight may be placed on one physician's opinion than another's depending on factors such as the reasoning employed by the physicians. Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994). Additionally, while the findings of a physician are medical conclusions that the Board cannot ignore or disregard, Willis v. Derwinski, 1 Vet. App. 66 (1991); the Board is free to assess medical evidence and is not obligated to accept a physician's opinion. Wilson v. Derwinski, 2 Vet. App. 614 (1992). After considering the entirety of the evidence of record, the Board finds the opinions from the April 2010 VA examiners who conducted the arteries and veins and peripheral nerves examinations to be more probative than that provided by April 2010 VA dermatology examiner. Namely, that it was as likely as not that the varicose vein condition was service related; the stasis dermatitis was secondary to the varicose vein condition; and that the Veteran had a history of service connection for rheumatoid arthritis (left knee disability) and rheumatoid arthritis was a known cause of generalized peripheral neuropathy; therefore, it was at least as likely as not that his peripheral neuropathy was related to his military service. The Board also finds persuasive Ms. N.A.'s statement that varicosities can be caused when fluid in the joints increases and additional pressure is placed on the circulatory system causing varicosities, noting that the Veteran's medical records revealed swelling of his left lower leg below his affected (service-connected) left knee which remained chronically effused and requiring intermittent joint aspiration. She opined, in pertinent part, that varicosities had a casual relationship to his service-connected condition. The arteries and veins and peripheral nerves examiners' opinions are well-supported and consistent with the documented record, to include the Veteran's credible and competent account of his symptoms and the aforementioned opinions submitted by Ms. N.A. The Board notes that Ms. N.A. also supported her opinions with multiple medical Internet articles associated with the claims file. The VA dermatology examiner provided no rationale to support his opinion. In assessing evidence such as medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). In fact, a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). Thus, it is established that the Veteran has current diagnoses of varicose veins, stasis dermatitis, and peripheral neuropathy, and he is service-connected for a left knee disability. Finally, the April 2010 VA examiners who conducted the arteries and veins and peripheral nerves examinations and Ms. N.A. provided a positive nexus between the varicose veins and the left knee disability, the stasis dermatitis and varicose veins, and peripheral neuropathy and the left knee disability. Therefore, all elements required for a grant of secondary service connection have been met here. The Board notes that in reaching this conclusion, the evidence is at least in equipoise, and the benefit of the doubt doctrine has been appropriately applied. See 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). (CONTINUED ON NEXT PAGE) The Duty to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). In this case, the Board is granting in full the benefits sought on appeal. Accordingly, either the duty to notify or the duty to assist need not be further discussed. ORDER Entitlement to service connection for varicose veins is granted, subject to governing criteria applicable to the payment of monetary benefits. Entitlement to service connection for stasis dermatitis is granted, subject to governing criteria applicable to the payment of monetary benefits. Entitlement to service connection for peripheral neuropathy is granted, subject to governing criteria applicable to the payment of monetary benefits. ____________________________________________ MARK GREENSTREET Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs