Citation Nr: 1323986 Decision Date: 07/29/13 Archive Date: 08/07/13 DOCKET NO. 11-22 093 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUE Entitlement to service connection for deep vein thrombosis and pulmonary emboli with pulmonary hypertension. REPRESENTATION Veteran represented by: The American Legion WITNESSES AT HEARING ON APPEAL Veteran and Dr. Carla Ehland, MD, MBA ATTORNEY FOR THE BOARD M. Taylor, Counsel INTRODUCTION Pursuant to 38 C.F.R. § 20.900(c), this appeal has been advanced on the Board's docket. The Veteran, who is the Appellant, served on active duty in the U.S. Marine Corps from December 1980 to December 1984. This matter is before the Board of Veterans' Appeals (Board) on appeal of a rating decision in December 2008 of a Department of Veterans Affairs (VA) Regional Office (RO). In December 2010, the Veteran appeared at a hearing before a Decision Review Officer. In August 2012, the Veteran appeared at a hearing before the undersigned Veterans Law Judge. Copies of the transcripts are in the Veteran's file. At the hearing in August 2012, the term "pulmonary aneurysm" was used to frame the issue, but the more exact term, on the basis of the evidence of record is "pulmonary emboli" and pulmonary emboli is used in this decision. In January 2013, in accordance with 38 U.S.C.A. § 7109, and 38 C.F.R. § 20.901(d), the Board obtained an advisory medical opinion from a physician who is not employed by VA (independent medical expert (IME)). In February 2013, the Board provided the Veteran and his representative a copy of the opinion and afforded the Veteran opportunity to submit additional argument and evidence. Additional argument and evidence was submitted. FINDING OF FACT The in-service left ankle injury with swelling, immobilization, and poor circulation resulted in venous damage superimposed on genetic hypercoagulability and the subsequent development of deep vein thrombosis and pulmonary emboli with pulmonary hypertension. CONCLUSION OF LAW The criteria for service connection for deep vein thrombosis and pulmonary emboli with pulmonary hypertension have been met. 38 U.S.C.A. §§ 1131, 5107(b) (West 2002), 38 C.F.R. § 3.303 (2012). The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented in part at 38 C.F.R § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate a claim. As the appeal is granted in full, VCAA compliance need not be addressed. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Principles of Service Connection Service connection may be granted for disability resulting from injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1131. To establish entitlement to VA disability compensation, a Veteran must show: (1) a present disability; (2) an 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, the so-called "nexus" requirement. All three elements must be proved. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed.Cir. 2004). Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if preexisting such service, was aggravated by service. This may be accomplished by affirmatively showing inception or aggravation during service. 38 C.F.R. § 3.303(a). Service connection may also be granted for a disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Evidentiary Standards VA must give due consideration to all pertinent medical and lay evidence in a case where a veteran is seeking service connection. 38 U.S.C.A. § 1154(a). The Veteran served in peacetime and the combat provisions of 38 U.S.C.A. § 1154(b) do not apply. Competency is a legal concept in determining whether medical or lay evidence may be considered, in other words, whether the evidence is admissible as distinguished from weight and credibility, a factual determination going to the probative value of the evidence, that is, does the evidence tend to prove a fact, once the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). The Board, as fact finder, must determine the probative value or weight of the admissible evidence. Washington v. Nicholson, 19 Vet. App. 362, 369 (2005) (citing Elkins v. Gober, 229 F.3d 1369, 1377 (Fed.Cir.2000) ("Fact-finding in veterans cases is to be done by the Board")). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the veteran. 38 U.S.C.A. § 5107(b). Facts On entrance examination in December 1980, there was no history or finding of hypercoagulability or pulmonary or vascular or lower extremity abnormality. The service treatment records show that in January 1981 the Veteran fell on pavement and hit his left knee. There was marked effusion and a contusion. X-rays showed no fracture. The assessment was traumatic effusion of the left knee. In February 1981, there was recurrent effusion and pain along the lateral joint line of the knee, exacerbated by repetitious running and marching. In March 1981, there was some residual discomfort over the lateral joint, but the knee was getting better. The pertinent findings were slight edema and fluid. Patellar bursitis was noted. In June 1981, the Veteran complained of left knee pain, after he had twisted his left knee five days earlier. There was no redness or swelling. The assessment was lateral collateral ligament strain. In October 1981, the Veteran sustained an injury to his left ankle, which was described as moderate to severe sprain. The same day the Veteran was seen for complaints of sweating, chills, dizziness, a productive cough, and fever. A chest X-ray showed a right lower lobe infiltrate and the assessment was pneumonitis. On follow-up the next day, the assessment was bronchitis. In November 1981, there was persistent edema of the left foot and ankle, but no leg streaking or erythema. X-rays did not show a fracture. The ankle was casted. In January 1982, there was apparent poor circulation and decreased range of motion in the left ankle. It was remarked that the Veteran did not seem to be progressing in his physical therapy program. On follow-up in February 1982, the Veteran stated that the ankle was feeling a little better and that he had been running. The Veteran stated that he kept the knee wrapped when running. It was noted that Veteran was doing well, but he was still unable to return to full duty or perform physical training. In March 1982, there was some residual left knee discomfort. It was noted that the ankle had been in a cast for about five weeks. The Veteran stated that he was able to run about two miles before the onset of pain. There was mild edema over the lateral malleolar area. From October 1981 to March 1982, the assessment was left ankle strain. In October 1982, the Veteran complained of a cough during and after physical training. The assessment was chest congestion. In November 1982 and in February 1984, X-rays showed calcified densities of the chest, which were thought to represent healed granulomatous disease, but no active process. In December 1984, on separation examination, there was no complaint, finding, or history of a pulmonary, vascular, or lower extremity abnormality. After service private hospital records show that in July 2006 the Veteran was admitted for evaluation of complaints of dizziness and chest pain. The Veteran also complained of progressive shortness of breath with exertion. Medical history was otherwise unremarkable. A chest X-ray was unremarkable. Cardiac catheterization was normal. It was reported that the etiology of the symptoms was unclear. On discharge, the pertinent diagnosis was acute myocardial infarction by elevated cardiac enzymes. Five days later in August 2006, the Veteran was readmitted because he was still having shortness of breath with exertion and chest pain. There was no complaint of leg pain. There was no recent immobilization or injury and no long travel by air or by flight and no prior history of deep vein thrombosis or pulmonary embolism. A CT scan of the chest showed pulmonary emboli. A Doppler venous ultrasound showed no clots from the groin to the popliteal region or knee, and the impression was a negative bilateral lower extremity venous ultrasound for deep vein thrombosis. A CT scan of the abdomen and pelvis for the source of the emboli was also negative. In a hematology work-up, protein C and protein S were normal. The Veteran was heterozygous positive for MTHFRC 677T (hypercoagulability). On discharge, the pertinent diagnoses were acute pulmonary embolism and positive for MTHFRC 677T (hypercoagulability). In August 2006, Dr. John C. Lantis, II, MD, the Director of Clinical Research at the Department of Endovascular-Vascular Surgery at Columbia University and Assistant Professor of Surgery, after a review of the record, recounted the Veteran's recent hospitalization for pulmonary emboli and that the Veteran was known to be heterozygous positive for MTHFRC 677T. Dr. Lantis order another ultrasound that showed occlusive thrombus in the region of the soleus and gastrocnemius muscle segments of the intramuscular veins and chronic changes in the posterior tibial veins. The impression was calf deep vein thrombosis of the left lower extremity. Dr. Lantis stated the Veteran had a remote history of trauma to the left ankle, resulting in possibly deep vein thrombosis. Dr. Lantis expressed the opinion that the combination of the left ankle trauma, resulted in residual scarring in the venous system, and hypercoagulability led to deep venous thrombosis, the antecedent to the pulmonary embolisms. In November 2006, the Veteran had an echocardiogram for pulmonary hypertension. In January 2007, in an evaluation by the State for a disability determination, the impression was shortness of breath due to pulmonary hypertension and pulmonary emboli In September 2007, the Veteran was granted disability benefits by the Social Security Administration, beginning in July 2006, in part, due to pulmonary hypertension and a history of pulmonary emboli. In his application for VA disability compensation in September 2007 and in a statement in support of his claim in October 2007, the Veteran stated that in service he was treated for left lower leg pain and swelling, that his leg was casted several times, that the pain persisted despite the casts, that he has deployed in 1982 and in 1984, and that chest X-rays showed calcified densities in the lungs. The Veteran asserted that leg pain and swelling were due to a blood clot in his left leg and that the calcific densities were pulmonary embolisms, which were the cause of his current disability. In August 2008, the Veteran was seen by VA for pulmonary hypertension. Cardiac catheterization did not show pulmonary hypertension. The VA physician explained that the pulmonary hypertension resolved after the pulmonary embolisms, because of recannulization of the pulmonary arteries. In October 2008, a VA physician reviewed the Veteran's file. After a review of the Veteran's history, including the service treatment records, the reports of hospitalization in 2006, which included diagnoses of pulmonary emboli, deep vein thrombosis, pulmonary hypertension, and a positive test for MTHFRC 677T, and the report of Dr. Lantis, the VA physician stated that there was no evidence to support the conclusion that the left ankle sprain in 1982 was related to the pulmonary emboli in 2006 and that the acute symptoms in hospitalizations in 2006 were the result of an abnormal anticoagulation profile. The VA physician expressed the opinion that it was not likely that the left ankle sprain was related to the hypercoagulability stated, a predisposing factor to venous thrombosis and possibly pulmonary embolism. In January 2009, after a review of the Veteran's service treatment records, Dr. Lantis stated that the history of multiple trauma to the left lower extremity and immobilization, resulted in an undiagnosed deep vein thrombosis, and that the residual scar from the undiagnosed deep vein thrombosis combined with the prethrombotic genetic mutation (MTHFRC 677T, hypercoagulability) led to the deep vein thrombosis in 2006, which was antecedent to the pulmonary embolism. Dr. Lantis stated that in August 2006 the pertinent findings were chronic venous insufficiency, varicose veins, spider veins, calf swelling, and edema. Dr. Lantis expressed the opinion that the current pulmonary status and pulmonary hypertension were secondary or due to deep vein thrombosis that more likely than not was precipitated by lower leg traumas and subsequent immobilizations that the Veteran had encountered as a result of injuries in 1981 and 1982. In statements in January 2009 and in August 2011, in addition to the entries in the service treatment records, the Veteran asserted that after a flight to and from Okinawa and back he experienced dizziness, fever, and chills. The Veteran stated that during the remainder of his enlistment he was bothered by persistent symptoms of pain, swelling, fatigue, and cramping in his left leg, which he then attributed to the demands of physical training, but in retrospect were the same symptoms he had in 2006, when he had a pulmonary embolism. The Veteran stated that left knee trauma and the left ankle trauma were superimposed on his inherited blood-clotting status (hypercoagulability), resulting in deep vein thrombosis in service and the subsequent development of pulmonary embolism and pulmonary hypertension. In support of his claim, the Veteran submitted a copy of a Board decision in 2007, granting service connection for deep vein thrombosis in a case involving an inherited protein C deficiency, causing abnormal blood clotting, with evidence of leg pain and cramping in service. The Veteran has also submitted articles on the causes and signs and symptoms of deep vein thrombosis and pulmonary embolism. In December 2010 at a hearing before a Decision Review Officer the Veteran set out his case for service connection, addressing the legal requirements for service connection. In July 2011, L.A.R., a fellow Marine, who served with the Veteran, stated that in October 1981 the Veteran had injured his left ankle. The Witness recalled that thereafter the Veteran had difficulty running because of cramping in the left calf muscle which has troubled the Veteran since then. In July 2011, D.R., who worked with the Veteran from 1988 to 2006, stated that the Veteran walked with a limp, which the Veteran stated was due to a left leg injury in service, which had bothered him by cramping and fatigue since then. In a statement in July 2012, the former VA staff Cardiologist and Director of Congestive Heart Failure services in Pittsburg stated that the Veteran had been under his care from September 2009 through May 2012. The VA physician stated that a repeat cardiac catheterization showed exercised induced hypertension. The VA physician stated that the cardiopulmonary compromise was more likely than not related to the history of chronic thromboembolic disease with deep vein thrombosis in 2006 and acute pulmonary embolism. After a review of the opinion by Dr. Lantis and the service treatment records as well as the Veteran's personal description of his injury and convalescence, the VA physician expressed the opinion that it was at less as likely as not that the Veteran suffered an initial deep vein thrombosis after the initial orthopedic injury [in service]. In August 2012, the Veteran testified about the left knee and left ankle injuries in service as well as airborne training and symptoms of swelling and cramping and numbness. Dr. Ehland testified that the Veteran's injuries to the left lower extremity, immobilization by casting, and long flights were superimposed on the Veteran's genetic predisposition for blooding clotting (hypercoagulability), damaging the vasculature or circulatory systems, resulting in deep vein thrombosis, which was undiagnosed. Dr. Ehland explained that deep vein thrombosis is a significant risk factor for recurrent deep vein thrombosis and with recurrent deep vein thrombosis there is a high possibility of a pulmonary embolism with pulmonary hypertension, which in the Veteran's case occurred in 2006. Dr. Ehland also stated that the deep vein thrombosis development in the injured left lower extremity and not the right lower extremity that was not injured. Dr. Ehland expressed the opinion that it was at least as likely as not that the Veteran's current venous thromboembolism was related to the events described in the service treatment records. In January 2013, the Board obtained an advisory medical opinion from a physician who is not employed by VA (independent medical expert (IME)). The IME, Associate Professor and Chair of the Department of Internal Medicine at a state university school of medicine, was asked to respond to the following questions 1. Whether it is more likely than not (probability greater than 50 percent), at least as likely as not (probability approximately 50 percent) or less likely than not (probability less than 50 percent) that the Veteran's in-service symptoms in 1981 of fever, chills, dizziness, and light headedness, which were treated during service as pneumonitis or bronchitis, were actually signs of a deep vein thrombosis, resulting in a pulmonary embolism? In response to Question 1, the IME stated that the following multiple injuries to the lower extremities the Veteran developed signs of tissue injury involving the left knee and left ankle, including edema and redness, but not extensive inflammation, thrombophlebitis, hotness, or cellulitis associated with deep vein thrombosis. As for fever, which may be sign of deep vein thrombosis and pulmonary embolism, the IME stated that chills also described were not. The IME expressed the opinion that it was less likely than not the symptoms in service were related to deep vein thrombosis and pulmonary embolism and at least as likely as not the symptom were related to a pulmonary infection. 2. Whether it is more likely than not (probability greater than 50 percent), at least as likely as not (probability approximately 50 percent) or less likely than not (probability less than 50 percent) that the that the left lower extremity deep vein thrombosis and pulmonary embolism in 2006 was caused by the left knee and left ankle orthopedic problems in service, including immobilization by casting of the left lower extremity for five weeks and prolonged sitting on intercontinental flights? In response to Question 2, the IME stated that while it is plausible that the left lower extremity injuries in service may have resulted in structural damage to the venous system and contributed to venous thromboembolism in 2006, the facts in the record are against the scenario. The IME stated that the [first] Doppler studies in August 2006 showed no evidence thrombosis and that the pulmonary thrombosis resulting in pulmonary embolism was related to hypercoagulability rather than an embolic phenomenon. The IME expressed the opinion that it was less likely than not the pulmonary emboli were related to the injury sustained in service and more likely than not that the pulmonary emboli were related to the genetic defect and the hypercoagulable state. In March 2013, Dr. Ehland responded to the report of the IME. Dr. Ehland stated that the IME did not consider evidence vital to the Veteran's claim, namely, a Doppler study in 2006 showing deep vein thrombosis in the calf muscles of the left leg, but not on the right side. Dr. Ehland expressed the opinion that it was more likely than not that the left leg orthopedic problems in service, requiring immobilization and manifested by poor circulation and persistent swelling, resulted in deep vein thrombosis, and subsequently to pulmonary embolisms with pulmonary hypertension in 2006. In April 2013, Dr. A.L. Sico, D.O., MPH, stated that the first Doppler study was from the groin to the knee and that the second Doppler study was from the groin to the ankle, which did show deep vein thrombosis in the left calf muscles, which accounted for the fact that the first study was normal, but limited. Dr. Sico expressed the opinion that it was more likely than not that the orthopedic problems in service caused deep vein thrombosis and pulmonary embolism wit pulmonary hypertension. Analysis The service treatment records show that in October 1981 the Veteran sustained an injury to his left ankle, which was described as a moderate to severe sprain. In November 1981, there was persistent edema of the left foot and ankle, but no leg streaking or erythema. X-rays did not show a fracture. The ankle was casted. In January 1982, there was apparent poor circulation and decreased range of motion in the left ankle. It was remarked that the Veteran did not seem to be progressing in his physical therapy program. On follow-up in February 1982, the Veteran stated that the ankle was feeling a little better and that he had been running. In March 1982, it was noted that the ankle had been in a cast for about five weeks. The Veteran stated that he was able to run about two miles before the onset of pain. There was mild edema over the lateral malleolar area. From October 1981 to March 1982, the assessment was left ankle strain. On the basis of the service treatment records alone, deep vein thrombosis and pulmonary emboli with pulmonary hypertension were not affirmatively shown to have been present during service. And service connection under 38 U.S.C.A. § 1131 and 38 C.F.R. § 3.303(a) (affirmatively showing inception in service) is not established. In statements and in testimony the Veteran has stated that he has had persistent left leg cramping and swelling since service. A fellow Marine, who served with the Veteran recalled that after the Veteran injured his ankle the Veteran had difficulty running because of cramping in the left calf muscle, which has troubled the Veteran since then. D.R., who worked with the Veteran from 1988 to 2006, stated that the Veteran walked with a limp, which the Veteran stated was due to a left leg injury in service, which had bothered him by cramping and fatigue since then. The Veteran and the witnesses are competent to describe symptoms, which are either within the realm of the Veteran's personal experience or are capable of lay observation by a witness. 38 C.F.R. § 3.159 (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.); see Layno v. Brown, 6 Vet. App. 465, 469-71 (1994) (lay testimony is competent as to symptoms of an injury or illness, which are within the realm of one's personal knowledge, personal knowledge is that which comes to the witness through the use of the senses; lay testimony is competent only so long as it is within the knowledge and personal observations of the witness). The Veteran's statements and testimony and the statements of the witnesses raise the theory of service connection on the basis of chronicity and continuity of symptomatology under 38 C.F.R. § 3.303(b). But the provisions pertaining to chronicity and continuity of symptomatology do not apply, because deep vein thrombosis and pulmonary emboli with pulmonary hypertension are not chronic diseases enumerated in 38 C.F.R. § 3.309(a), the only regulation listing chronic diseases. See Walker v. Shinseki, 708 F.3d 1131 (Fed. Cir. 2013) (The continuity of symptomatology avenue to service connection under regulation creating presumption of service connection for chronic diseases manifesting during service and then again at any later date is available only for chronic diseases enumerated in the only regulation listing named chronic diseases 38 C.F.R. §§ 3.303(b), 3.309(a)). Nevertheless service connection may be still be established pursuant to 38 C.F.R. § 3.303(d) for a disability diagnosed after service when competent and credible evidence links the disability to service. The Veteran is competent to describe left leg cramping and swelling after service, which is capable of lay observation, and the Veteran as lay person is also competent to identify a simple medical condition and the Veteran as a lay person is competent to offer an opinion on a simple medical condition. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (a lay person is competent to identify a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional); and see Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (a lay person is also competent to offer an opinion on a simple medical condition). Deep vein thrombosis and pulmonary emboli with pulmonary hypertension are not simple medical conditions the Veteran is competent to identify, because the diagnoses fall outside the realm of common knowledge of a lay person, that is, the diagnosis cannot be made based on mere personal observation, which comes through sensory perception. Although the Veteran has worked in the medical field it is not argued or shown that the Veteran is otherwise qualified through specialized education, training, or experience to identify vascular diseases, such as deep vein thrombosis. Also deep vein thrombosis and pulmonary emboli with pulmonary hypertension are not the types of conditions under case law that has been found to be capable of lay observation. See Falzone v. Brown, 8 Vet. App. 398, 405 (1995) (flatfeet are capable of lay observation); see McCartt v. West, 12 Vet. App. 164, 167 (1999) (a skin condition is capable of lay observation; see Charles v. Principi, 16 Vet. App. 370, 374 (2002) (tinnitus is capable of lay observation); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis); and see Jandreau, at 1377, n. 4 (a lay witness is capable of diagnosing a dislocated shoulder or a simple medical condition, for example a broken leg, but not, for example, a form of cancer). Applying the guidance of current case law, deep vein thrombosis and pulmonary emboli with pulmonary hypertension are internal disease processes such as rheumatic fever or cancer rather than either flatfeet, a skin condition, tinnitus, varicose veins, a dislocated shoulder, or a broken leg. For this reason, deep vein thrombosis and pulmonary emboli with pulmonary hypertension are not the types of conditions under case law that have been found to be capable of lay observation. As deep vein thrombosis and pulmonary emboli with pulmonary hypertension are not the types of conditions that can be identified based on personal observation either as a simple medical condition under Jandreau, or by case law, any inference based on what is not personally observable cannot be competent lay evidence. And no factual foundation has been established to show that the Veteran is otherwise qualified through specialized education, training, or experience to offer an opinion on the causal relationship or nexus between deep vein thrombosis and pulmonary emboli with pulmonary hypertension and the left ankle injury in service. For these reasons, the Veteran lay opinion is not competent evidence of a causal relationship or nexus between deep vein thrombosis and pulmonary emboli with pulmonary hypertension and the in-service injury. Since the Veteran's lay opinion is not competent evidence, the Veteran's lay opinion is excluded, that is, not admissible as evidence and cannot be considered as competent lay evidence favorable to claim. As the Veteran's lay evidence is not competent evidence on the material issues of fact, pertaining to the diagnosis of deep vein thrombosis and pulmonary emboli with pulmonary hypertension and medical causation, the Board looks to the medical evidence. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer a medical diagnosis, statement, or opinion. 38 C.F.R. § 3.159. As for the Veteran reporting a contemporaneous medical diagnosis, after service deep vein thrombosis and pulmonary emboli with pulmonary hypertension were first diagnosed in 2006. Although it is argued that the medical conditions were present before 2006, it is not argued or shown that the medical conditions were diagnosed before 2006. As for symptoms described by the Veteran that later support a diagnosis by a medical professional, there is competent medical evidence for and against the claim, pertaining to causation or a nexus to service. The probative value or evidentiary weight to be attached to a medical opinion is within the Board's province as finder of fact. The guiding factors in evaluating the probative value of a medical opinion include whether the opinion is based upon sufficient facts, and whether the expert applied valid medical analysis to the significant facts of the case in order to reach the conclusion rendered in the opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-3 (2008). The competent medical evidence of record pertaining to causation or a nexus to service favorable to the claim consists of the opinions of Dr. Lantis, a VA cardiologist, Dr. Ehland, and Dr. Sico. From the evidence cited in the favorable medical opinions the Board finds that the significant facts of the case include an in-service left ankle injury, requiring immobilization by cast for about five weeks and subsequent findings of poor circulation and persistent swelling, and after service in 2006 genetic hypercoagulability (heterozygous positive for MTHFRC 677T), pulmonary embolisms by CT scan, deep vein thrombus in the left calf muscles by Doppler study, and pulmonary hypertension. Based on these facts, Dr. Lantis stated that the history of multiple trauma to the left lower extremity and immobilization, resulted in an undiagnosed deep vein thrombosis, and that the residual scar from the undiagnosed deep vein thrombosis combined with genetic hypercoagulability) led to the deep vein thrombosis in 2006, which was antecedent to the pulmonary embolism. A VA cardiologist expressed the opinion that it was at less as likely as not that the Veteran suffered an initial deep vein thrombosis after the initial orthopedic injury in service. Dr. Ehland testified that the Veteran's injuries to the left lower extremity, immobilization by casting, and long in-service overseas flights were superimposed on the Veteran's genetic predisposition for blooding clotting (hypercoagulability), damaging the vasculature or circulatory systems, resulting in deep vein thrombosis, which was undiagnosed. Dr. Ehland also expressed the opinion that it was more likely than not that the left leg orthopedic problems in service, requiring immobilization and manifested by poor circulation and persistent swelling, resulted in deep vein thrombosis, and subsequently to pulmonary embolisms with pulmonary hypertension in 2006. Dr. Sico, D.O., stated that the first Doppler study was from the groin to the knee and that the second Doppler study was from the groin to the ankle, which did show deep vein thrombosis in the left calf muscles, which accounted for the fact that the first study was normal, but limited. Dr. Sico expressed the opinion that it was more likely than not that the orthopedic problems in service caused deep vein thrombosis and pulmonary embolism with pulmonary hypertension. The favorable medical opinions show that the Veteran suffered a left ankle injury in service, requiring immobilization by a cast and subsequently poor circulation and persistent swelling, damaging the venous system that was superimposed on genetic hypercoagulability, resulting in deep vein thrombosis the antecedent to pulmonary embolisms with pulmonary hypertension. The evidence is inconclusive as to whether deep vein thrombosis was present and undiagnosed in service, but not that the Veteran initial suffered damage to the venous system, developing at some point, not clear from the record, in deep vein thrombosis. The competent medical evidence of record pertaining to causation or a nexus to service against claim consists of the opinions of VA physician and an IME physician. The VA physician stated that the acute symptoms in hospitalizations in 2006 were the result of an abnormal anticoagulation profile, not due to the left ankle injury inservice. The VA physician stated that the finding of deep vein thrombosis on the basis of a small venous branch of a calf muscle was unreliable. The IME physician expressed the opinion that it was less likely than not the pulmonary emboli were related to the injury sustained in service and more likely than not that the pulmonary emboli were related to the genetic defect and the hypercoagulable state. Both VA and IME physicians concurred that the findings in 2006 were the result of an abnormal anticoagulation profile, not due to the left ankle injury in service. The VA examiner rejecting deep vein thrombosis as the cause of the pulmonary emboli with pulmonary hypertension. The IME did not address the evidence of deep vein thrombosis. When, after careful consideration of the entire record, a reasonable doubt arises regarding a material issue of fact, such doubt will be resolved in favor of the Veteran. By reasonable doubt is meant one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. Whereas here the essential facts are not disputed, and the same set of facts have resulted in contradictory opinions, the Board finds that there is an approximate balance of positive and negative evidence, which does not satisfactorily prove or disprove the claim of service connection. As there is a reasonable doubt, which is resolved in the Veteran's favor, 38 C.F.R. § 3.102, service connection is warranted. With the favorable outcome, the Board need not address the other arguments pertaining to whether a pulmonary embolism was present and undiagnosed in service. ORDER Service connection for deep vein thrombosis with pulmonary emboli and pulmonary hypertension is granted. ____________________________________________ George E. Guido Jr. Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs