Citation Nr: 1327149 Decision Date: 08/26/13 Archive Date: 08/29/13 DOCKET NO. 09-41 933A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Milwaukee, Wisconsin THE ISSUES 1. Entitlement to service connection for venous stasis, to include as secondary to service-connected diabetes mellitus type II. 2. Entitlement to service connection for hypertension, to include as secondary to service-connected diabetes mellitus type II. 3. Entitlement to service connection for peripheral neuropathy of the lower extremities, to include as secondary to service-connected diabetes mellitus type II. 4. Entitlement to service connection for a heart disorder, to include as secondary to service-connected diabetes mellitus type II. 5. Entitlement to service connection for a disorder manifested by sharp pains in the pelvic area, to include as secondary to service-connected diabetes mellitus type II. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Donna D. Ebaugh, Counsel INTRODUCTION The Veteran had active duty from April 1966 to August 1966 and from May 1968 to August 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2008 rating decision of the RO in Milwaukee, Wisconsin. The Board notes that, in addition to the paper claims file, there is a Virtual VA paperless claims file. A review of the documents in such file reveals an Informal Hearing Presentation dated in June 2013 that is not included in the paper file. The remainder of the documents in the virtual file are either duplicative of the evidence in the paper claims file or are irrelevant to the issue on appeal. The issues of entitlement to service connection for a heart disorder and a disorder manifested by sharp pains in the pelvic area, both to include as secondary to service-connected diabetes mellitus type II, are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran served in the Republic of Vietnam during the Vietnam Era. 2. The Veteran's venous stasis and hypertension are not related to any disease, injury, or incident of service, did not manifest within one year of service discharge, and were not caused or aggravated by a service-connected disability. 3. At no time during the period on appeal did the Veteran have a diagnosis of peripheral neuropathy of the lower extremities. His bilateral lower extremity disorder of sciatica was not caused or aggravated by a service-connected disability. CONCLUSIONS OF LAW 1. Venous stasis was not incurred in or aggravated by the Veteran's active duty military service, may not be presumed to have been incurred in or aggravated by such service, and is not proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 1110, 1112, 1113, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2012). 2. Hypertension was not incurred in or aggravated by the Veteran's active duty military service, may not be presumed to have been incurred in or aggravated by such service, and is not proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 1110, 1112, 1113, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2012). 3. A bilateral lower extremity disorder was not incurred in or aggravated by the Veteran's active duty military service, may not be presumed to have been incurred in or aggravated by such service, and is not proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 1110, 1112, 1113, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on the claim for VA benefits. In the instant case, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, a May 2008 letter, sent prior to the initial October 2008 rating decision that denied the Veteran's claims on direct, presumptive, and secondary bases, advised the Veteran of the evidence and information necessary to substantiate his service connection claims on direct, presumptive, and secondary bases as well as his and VA's respective responsibilities in obtaining such evidence and information. Additionally, the May 2008 letter advised him of the information and evidence necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. In addition, the duty to assist the Veteran has also been satisfied in this case. The Veteran's service treatment records as well as all identified and available post-service VA and private medical records are of record and were reviewed by both the RO and the Board in connection with the Veteran's claim. The Veteran has not identified any outstanding records that are pertinent to his appeal. Also of record is a transcript from his hearing before the Decision Review Officer prior to certification to the Board. The Veteran was also provided the opportunity to testify at a hearing before the Board although he declined to do so. The Veteran was afforded VA examinations in June 2008 and September 2009 with respect to the issues decided herein. The Board acknowledges that the June 2008 VA examiner did not review the Veteran's claims file, but the Board finds that this is not a fatal flaw. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion comes from when it is the factually accurate, fully articulated, and sound reasoning for the conclusion). Here, the June 2008 VA examiner considered the Veteran's statements and conducted a thorough examination of the Veteran in rendering the nexus opinions for venous stasis and hypertension. The Board finds the opinion was incomplete as it relates to the bilateral lower extremity disorder because the examiner merely determined that there was no diagnosis of peripheral neuropathy but did not offer a nexus opinion on the current disability of sciatica of the bilateral lower extremities. However, as discussed below, the Veteran is not prejudiced by the inadequate examination since he was provided a subsequent, adequate examination in September 2009. Further, the Board finds that the September 2009 VA opinion of record is adequate to decide the issues, as it is predicated on a review of the claims file, which includes the Veteran's statements, his service treatment records, and post-service treatment records, as well as a thorough examination of the Veteran. Additionally, the opinions proffered considered all of the pertinent evidence of record, to include the statements of the Veteran, and provided a complete rationale, relying on and citing to the records reviewed. The Board acknowledges that neither the June 2008 nor the September 2009 VA examiner offered opinions with respect to direct service connection. The Court of Appeals for Veterans Claims (the Court) in McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006), held that a VA examination or opinion must be provided when there is: (1) competent evidence of current disability or recurrent symptoms; (2) establishment of an in-service event, injury, or disease; (3) an indication that the current disability may be associated with the in-service event; and (4) insufficient competent medical evidence to decide the claim. Here, as explained below, the evidence of record does not demonstrate any indication that the current disabilities may be associated with the in-service events. As such, an opinion regarding direct service connection is not required. Based on the foregoing, the Board finds that the June 2008 and September 2009 VA examination reports and opinions are adequate to decide the Veteran's claims for service connection of venous stasis and hypertension, as the examiners offered clear conclusions with supporting data as well as a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet.App. 120, 124 (2007) ("[A]medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Further, the Board finds that although the June 2008 VA opinion was incomplete with respect to the bilateral lower extremity disorder, the September 2009 VA opinion was adequate and compensated for any deficiencies with the prior examination. The Veteran was also provided an opportunity to set forth his contentions during a DRO hearing in August 2010. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the RO Decision Review Officer or Veterans Law Judge who chairs a hearing fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the August 2010 hearing, the DRO enumerated the issues on appeal. Also, information was solicited regarding onset of the Veteran's claimed venous stasis, hypertension, and bilateral lower extremity disorder and any causal link between the claimed disorder and his diabetes mellitus, type II. Therefore, the hearing focused on the elements necessary to substantiate the Veteran's claims, to include the necessity of a causal connection between his claimed disorders and his service-connected diabetes mellitus, type II, which he claims caused or aggravated the disorders. Therefore, not only were the issues "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim," were also fully explained. See Bryant, 23 Vet. App. at 497. Moreover, the hearing discussion did not reveal any evidence that might be available that had not been submitted by the Veteran or otherwise obtained by VA. Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, he will not be prejudiced as a result of the Board proceeding to the merits of his claims. II. Analysis This appeal arises out of the Veteran's assertion that venous stasis, hypertension, and peripheral neuropathy of the lower extremities are related to his service-connected diabetes mellitus, type II. Alternatively, the Veteran has asserted that the disorders are related to his active duty, including service in Vietnam. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Additionally, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as hypertension, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). The use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc); see also Wallin v. West, 11 Vet. App. 509, 512 (1998). The Board notes that 38 C.F.R. § 3.310 was amended effective October 10, 2006. Under the revised § 3.310(b) (the existing provision at 38 C.F.R. § 3.310(b) was moved to sub-section (c)), any increase in severity of a nonservice-connected disease or injury proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the disease, will be service-connected. The revised regulation requires comparison of the baseline level of severity of the disorder in the absence of the service-connected disability to the increased severity, and provides compensation only if there is an increase in severity. 38 C.F.R. § 3.310 (2012). Additionally, VA regulations provide that a Veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the Vietnam era, namely from February 28, 1961, to May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the Veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307(a)(6)(iii). The Board notes that the Veteran's service personnel records reflect service in Vietnam during the relevant time period. As such, the Board finds that the Veteran is presumed to have been exposed to herbicides coincident with service in the Republic of Vietnam. If a Veteran was exposed to an herbicide agent during active service, presumptive service connection is warranted for numerous disorders; however, hypertension and venous stasis are not included on such list. 38 C.F.R. § 3.309(e), as amended, 75 Fed. Reg. 53,203 (August 31, 2010). In this regard, VA's Secretary has determined that a presumption of service connection based on exposure to herbicides used in the Republic of Vietnam during the Vietnam era is not warranted for any condition for which the Secretary has not specifically determined a presumption of service connection is warranted. See 68 Fed. Reg. 27,630 (May 20, 2003). Notably, acute and subacute peripheral neuropathy is included on the list of presumptive diseases. Lay testimony is competent to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994). When a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303 (2007). 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, (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. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). 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 claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). a. Venous Stasis The Veteran claims that he has venous stasis secondary to his diabetes mellitus, type II. Alternatively, he argues that his venous stasis is caused by his active duty, including service in Vietnam. At his August 2010 hearing before the Decision Review Officer, the Veteran explained that he had three "venostasis ulcers" in his ankle. He reported that the first one was in 2001, the second in 2005, and the third in 2008. He reported that a "venostasis ulcer is a hole in [the] ankle developing from the inside due to... lack of circulation and it burns like hell and it lasted for approximately six months each time." He described treatment with compression stockings and a doctor who "burned out a vein or two... to prevent this..." He reported that his venostasis was an ongoing problem and that he continued to wear compression stockings to prevent the venostasis ulcers. His wife also testified that he had been wearing compression stockings for many years. A review of treatment records reveals that the Veteran sought treatment for venous disorders in his legs, beginning in 1994. Private treatment records dated in 1994 discuss stenting procedures that the Veteran underwent. A letter from a private cardiologist, Dr. H., dated in June 1994 indicates that the Veteran's "aortoiliofemoral arteriogram revealed a high grade stenosis in the distal left common iliac and a somewhat less severe but still highly significant stenosis in the proximal right common iliac." The cardiologist referenced the Veteran's "claudication problem" and noted that it may be solved by stent deployment in both common iliac arteries. A subsequent June 1994 private treatment record confirmed that the stent deployment procedure was completed in both of the iliac arteries. In March 1997, Dr. H. noted that his right iliac system was "diffusely diseased and occluded proximally." Dr. H. explained that as they "explored the occlusion it became obvious that it extended much higher into the aorta." Dr. H. then sent the Veteran for a full aorto-ilio-femoral arteriogram, which revealed a "classic Leriche syndrome with occlusion of the aorta just below the left renal." Dr. H. noted that the Veteran would need an aorto-bi-femoral graft and that he might need the renal artery to the lower pole of his left kidney reimplanted as part of the procedure. The Veteran underwent the procedure in April 1997. A July 2003 letter from Dr. P. indicated that the Veteran had been diagnosed with diabetes mellitus, type II. A pertinent VA outpatient treatment record dated in June 2008 noted that the Veteran presented with claudication. The VA physician noted that an ankle-brachial index showed mild ischemia bilaterally in the lower extremities reflected by ankle-brachial indices at rest of 0.85 on the right and 0.87 on the left. PVR waveforms were consistent with the index. The Veteran was diagnosed with mild ischemia in the lower extremities. The Veteran underwent a VA examination in June 2008. The June 2008 VA examiner noted that the Veteran had left venous stasis since his aorto bifemoral bypass in 1997. The examiner also noted that he had two ulcers on the left that had healed. The examiner noted that the Veteran had worn elastic stockings on the right since 1997. The Veteran reported that he was not sure how long he had had venous stasis on the right but that he had become aware of hyperpigmentation on the right about 3-4 years prior to the June 2008 VA examination and had been told by his doctor that it was due to venous stasis. He reported that he began to wear compression stockings on the right at that time. On physical examination, the June 2008 VA examiner noted that the Veteran had bilateral lower extremity superficial varicosities over distal medial legs with venous stasis changes but no ulcers. The examiner also noted that the Veteran's feet were warm with absent pedal pulses. The examiner assessed bilateral lower extremity peripheral vascular disease (PVD). The examiner opined that the PVD was not caused by diabetes mellitus, type II, as it developed years prior to the diabetes. The examiner also opined that the PVD was due to the Veteran's tobacco use and hypertension. The examiner noted that she was unable to offer an opinion regarding whether his PVD was aggravated by diabetes mellitus, type II, as it would require speculation. The examiner explained that she was unable to determine how long the Veteran had diabetes and that she did not have any baseline for the PVRs. She explained that his PVRs only showed mild peripheral vascular disease and that his symptoms of claudication seemed to be neurogenic claudication due to his back and not to PVD. She also noted that his diabetes had been very well-controlled for the year prior to the examination with almost normal fasting sugars and normal HGBA1cs. She acknowledged that she had no record regarding control prior to 2008. Lastly, she commented that she suspected that there was no aggravation, but reiterated that she could not say that without resort to speculation. The Veteran underwent another VA examination in September 2009. At that time, the September 2009 VA examiner also diagnosed peripheral vascular disease of the bilateral lower extremities. The examiner also observed that there was no venous stasis on examination. At the September 2009 VA examination, the Veteran reported that he had been diagnosed with diabetes mellitus, type II, "around 2003." He also reported that the vascular problems had started in 1994. He also indicated that he "doesn't really think the vascular problems have been worse since he was diagnosed with his [diabetes mellitus type II]." The Veteran reported to the examiner that he did not know the reasoning behind his appeal other than that his service officer had assisted him with it. He reported that he got cramping in his bilateral legs any time he walked and that after two blocks, he had to rest. He denied any symptoms at rest. On physical examination, the examiner noted that both feet were "warm with good cap refill" and there were nonpalpable pulses. The September 2009 VA examiner opined that the Veteran's PVD was not caused or aggravated by his diabetes mellitus, type II. The examiner offered rationale that the "records clearly show the [V]eteran had extensive PVD prior to his [diabetes mellitus, type II] diagnosis almost certainly caused by smoking. There is no indication of worsening disease." The Veteran has primarily based his claim on secondary service connection. In this regard, he has a current disability and is service-connected for diabetes mellitus, type II. However, the claim fails on a secondary basis, as there is no indication that his current disability was caused or aggravated by his service-connected diabetes mellitus, type II. Regarding causation of venous stasis, or a venostasis ulcer, the earliest diagnosis of diabetes mellitus, type II, is in 2003, nine years after the earliest indication of any venous symptomatology. The Board places high probative value on the June 2008 and September 2009 VA examiners' opinions that the PVD could not have been caused by diabetes mellitus, type II, as it began prior to the diagnosis of diabetes mellitus, type II. The Board notes that the first indication of a diagnosis of diabetes mellitus, type II, is the July 2003 letter from Dr. P. Further, the Board places high probative weight on the June 2008 and September 2009 VA examiners' opinions that the Veteran's PVD was most likely caused by his history of smoking and/or hypertension. As explained below, service connection for hypertension is not warranted. Regarding aggravation of PVD by the service-connected diabetes mellitus, type II, the Board places high probative value on the September 2009 VA examiner's opinion that the Veteran's PVD was not aggravated, as "there is no indication of worsening disease." The Board finds this is particularly probative in light of the Veteran's own statement to the VA examiner that he did not believe that his PVD had worsened since he was diagnosed with diabetes mellitus, type II. Further, in his sworn testimony before the DRO, the Veteran indicated that he had experienced three venostasis ulcers in 2001, 2005, and 2008. Private treatment records confirm that he had a venostasis ulcer in August 2001. He reported that he wore compression stockings to prevent further venostasis ulcers. His testimony does not indicate that his symptoms worsened from the time that he was first diagnosed with a venostasis ulcer in 2001 and his diagnosis of diabetes mellitus, type II, in 2003. As the June 2008 and September 2009 VA examiners offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two, the Board accords great probative weight to their opinions. See Nieves-Rodriguez, supra; Stefl, supra. For the foregoing reasons, the Board finds that the preponderance of the evidence is against the claim for service connection of venous stasis (or PVD) as secondary to service-connected diabetes mellitus, type II. The Board has also considered the claim on presumptive and direct bases as well. However, the claim fails on a presumptive basis, as the earliest indication of any venous symptoms was in the mid-late 1990's, nearly 30 years post-service. The Veteran does not claim otherwise. As the venous symptoms were not manifested within one year of service, the claim for service connection fails on a presumptive basis. Regarding direct service connection, the Veteran's service treatment records are silent as to any complaints of leg swelling or diagnosis of any venous insufficiency. Venous insufficiency is not listed as one of the disorders presumed to be associated with herbicide exposure. In fact, Note 3 to 38 C.F.R. § 3.309(e) specifically indicates that the term ischemic heart disease (which is included in the list of presumptive diseases) does not include peripheral vascular disease. Notwithstanding the presumption provisions, the Federal Circuit Court has determined that a claimant is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994); Ramey v. Brown, 9 Vet. App. 40, 44 (1996), aff'd sub nom. Ramey v. Gober, 120 F.3d 1239 (Fed. Cir. 1997), cert. denied, 118 S. Ct. 1171 (1998). See Brock v. Brown, 10 Vet. App. 155, 160-61 (1997). The Board has considered whether the Veteran may be entitled to service connection on a direct basis but finds that the claim fails for lack of a nexus to service. The Board has reviewed the medical evidence of record and finds no indication of a relationship between the Veteran's PVD, or venous stasis, and service. As discussed above, his service treatment records were silent as to any vascular disorder. The first indication of venous stasis was nearly 30 years following service. The Veteran does not claim otherwise. The Board acknowledges that the June 2008 and September 2009 VA examiners only offered opinions with respect to secondary service connection; however, as discussed above, a remand for a direct service connection opinion is not necessary, as there is no indication of a relationship between service and the Veteran's PVD or venous stasis. In reaching this conclusion, the Board has considered the Veteran's and his representative's statements that his PVD or venous stasis is related to service, including herbicide exposure in service. Although laypersons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011), as to the specific issue in this case, etiology of peripheral vascular disease or venous stasis disability falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). Based on the foregoing, the Board finds that service connection for venous stasis (or PVD) is not warranted on a presumptive, direct, or secondary basis. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for venous stasis. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. b. Hypertension The Veteran claims that he has hypertension secondary to his diabetes mellitus, type II. Alternatively, he argues that his hypertension is caused by his active duty, including service in Vietnam. There is no dispute that the Veteran has a current diagnosis of hypertension. The Veteran reported to the September 2009 VA examiner that his hypertension was diagnosed in 1988. The diagnosis is confirmed by treatment records. A private treatment record dated in December 1995 documents a diagnosis of hypertension. The Veteran underwent VA examinations in June 2008 and September 2009 in order to determine whether his hypertension was related to his service-connected diabetes mellitus, type II. In June 2008, the VA examiner noted that the Veteran's hypertension had been diagnosed approximately 20 years prior to the June 2008 VA examination. The examiner opined that the hypertension was unrelated to the Veteran's diabetes, as he had normal urine microalbumen and normal renal function. The September 2009 VA examiner noted that the Veteran's hypertension was diagnosed many years prior to the diabetes mellitus, type II. Like the June 2008 VA examiner, the September 2009 VA examiner also noted that the Veteran had no renal dysfunction and his urine microalbumin to creatine ratio was normal. The September 2009 VA examiner determined that because the Veteran's hypertension was diagnosed many years prior to diabetes mellitus, type II, and because he had no renal dysfunction and his urine microalbumin to creatine ratio was normal, his hypertension was not caused or aggravated by diabetes mellitus type II. The Board places high probative value on the June 2008 and September 2009 VA examiners' opinions that the Veteran's hypertension was not caused by diabetes, as it was diagnosed many years prior to the onset of his diabetes. Further, the Board places high probative value on the June 2008 and September 2009 VA examiners' opinions that the Veteran's hypertension was not aggravated by diabetes mellitus, type II, as objective testing did not reveal any renal dysfunction and his urine microalbumin to creatine ratio was normal. As the VA examiners offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two, the Board accords great probative weight to their opinions. See Nieves-Rodriguez, supra; Stefl, supra. The Board has reviewed the remaining private treatment records and VA outpatient treatment records and finds that they do not support a finding that his hypertension was caused or aggravated by his diabetes mellitus, type II. The Board has considered the Veteran's lay statements and sworn testimony from his DRO hearing, regarding his belief that his hypertension is related to his diabetes mellitus, type II. However, the Board finds that he is not competent to render an opinion regarding the etiology of his hypertension. See Kahana, 24 Vet.App. at 435; see also Jandreau, 492 F.3d at 1377 n.4. The Board has also considered whether the Veteran is entitled to service connection on presumptive and direct bases as well. The Veteran's service treatment records are negative for hypertension during service. There is no evidence of hypertension within one year after service. Rather, the earliest indication of hypertension was in 1988, 20 years post-service. First, there is no evidence of hypertension within one year after the Veteran's discharge. In this regard, the absolute earliest that the VA examiners and the Veteran himself place the onset of hypertension is in 1988, which is nearly 20 years after his service discharge. Moreover, the Veteran has not alleged a continuity of hypertension symptomatology between the time of his discharge and the diagnosis of such disease. See Walker, supra. Therefore, service connection based on the manifestation of a chronic presumptive disease within one year of service discharge is not warranted. As hypertension was not manifested within one year of service, the claim for service connection fails on a presumptive basis. Regarding presumptive service connection due to herbicide exposure, hypertension is not listed as one of the disorders presumed to be associated with herbicide exposure. In fact, Note 3 to 38 C.F.R. § 3.309(e) specifically indicates that the term ischemic heart disease (which is included in the list of presumptive diseases) does not include hypertension. Further, in July 2009, the National Academy of Sciences (NAS) issued "Veterans and Agent Orange: Update 2008" (Update 2008). The Secretary, based upon Update 2008 and prior NAS reports, has specifically concluded that a presumption of service connection based on exposure to herbicides in the Republic of Vietnam is not warranted for hypertension. See 75 Fed. Reg. 32540 (June 10, 2008). Notwithstanding the presumption provisions, the Federal Circuit Court has determined that a claimant is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994); Ramey v. Brown, 9 Vet. App. 40, 44 (1996), aff'd sub nom. Ramey v. Gober, 120 F.3d 1239 (Fed. Cir. 1997), cert. denied, 118 S. Ct. 1171 (1998). See Brock v. Brown, 10 Vet. App. 155, 160-61 (1997). The Board has considered whether the Veteran may be entitled to service connection on a direct basis but finds that the claim fails. The Veteran's service treatment records are silent as to any references to hypertension. As discussed above, the Veteran himself claims that the first diagnosis of hypertension was in 1988, nearly 20 years following service. Such a lapse of time is a factor for consideration in deciding a service connection claim. Maxson v. Gober, 230 F.3rd 1330, 1333 (Fed. Cir. 2000). Further, the Board has reviewed the medical evidence of record and finds no indication of a relationship between the Veteran's hypertension and service. The Board acknowledges that the June 2008 and September 2009 VA examiners only offered opinions with respect to secondary service connection; however, a remand for a direct service connection opinion is not necessary, as there is no indication of a relationship between service and the Veteran's hypertension. Based on the foregoing, the Board finds that service connection for hypertension is not warranted on a presumptive, direct, or secondary basis. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for hypertension. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. c. Bilateral Lower Extremities The Veteran claims that he has peripheral neuropathy secondary to his diabetes mellitus, type II. Alternatively, he argues that he has peripheral neuropathy caused by his active duty, including service in Vietnam. As an initial matter, there is no dispute that the Veteran has a current bilateral lower extremity disability, although there is some dispute as to whether he has a peripheral neuropathy disability or sciatica. A September 1994 private treatment record from Dr. H. noted that the Veteran complained of numbness and tingling in his left lateral thigh, and the physician noted that this is "probably related [to] previous back injury; he has known disc bulging in his lower spine." In a private treatment record from Dr. H. dated in November 1994, the Veteran reported that prior to bilateral stent deployment, he had "pain in the buttocks which radiated down the legs." Dr. H. noted that "[h]e has a known ruptured disc, and that may be the etiology of the discomfort that he is complaining of at this time." A January 1997 private treatment record from Dr. G. discussed the Veteran's EMG report that was within normal limits. A private treatment record dated in June 2008 noted the Veteran's complaints of low back pain with radiation down both legs that had been getting worse over the last 5-6 months. The Veteran reported pain radiating down the back of the legs and into the feet, especially after standing for extended periods. The Veteran also reported that he noticed pins and needles tingling in his feet when this happened. He denied weakness associated with it. The impression was low back pain with paresthesia down both legs concerning for spinal stenosis versus radiculopathy. The examiner ordered an MRI to evaluate. The subsequent June 2008 private MRI noted impressions of multiple disc bulges as well as a disc herniation. The impression was "degenerative changes in the lumbar spine, primarily consisting of mild broad-based disc bulge and significant facet arthropathy which causes mild to moderate central canal stenosis most pronounced at L4-5." The Veteran underwent a VA examination in June 2008 regarding his claimed bilateral lower extremity disorder. As discussed above, the June 2008 VA examination report was incomplete, as it merely noted that there was no finding of peripheral neuropathy, but did not address any other diagnosed bilateral lower extremity disability. A November 2008 letter from the Veteran's private physician Dr. P., noted that peripheral neuropathy was a very common complication of diabetes and should be reconsidered, and that the Veteran's pain in his feet appeared to be related to the diabetic neuropathy. Dr. P. also indicated that the Veteran had a normal monofilament examination. Dr. P. also noted that the Veteran had complaints of pain in his feet that "appears clearly related to diabetic neuropathy." The Veteran also underwent a VA examination in September 2009 for evaluation of his bilateral lower extremity disorder. At that time, he reported to the September 2009 VA examiner that he had numbness in all his toes that started 5 or 6 years prior, around the time of his diagnosis of diabetes mellitus, type II. He also reported a burning pain in both feet associated with the numbness. He reported flare-ups with walking about 5 or 6 times a day. He reported that the symptoms went away when he sat down and that the symptoms were worse with bending and walking. He reported that symptoms improved when he was in a grocery store and could lean over the cart while walking. He reported that he did not take medication or other treatment for his symptoms. On physical examination, the examiner noted the bilateral lower extremities had "normal sensation (including monofilament and vibratory testing), normal strength, normal DTR's and muscle tone." The examiner also noted that the Veteran had negative straight leg testing, bilaterally. The examiner diagnosed bilateral sciatica. Based on a review of the record as well as the physical examination, the September 2009 VA examiner diagnosed bilateral sciatica. The examiner determined that there was no bilateral lower extremity sensory polyneuropathy on examination. Instead, the examiner opined that the "[V]eteran's leg symptoms are most consistent with bilateral sciatica in a person with known central canal stenosis at L4/5 by MRI." At the Veteran's hearing before the DRO in August 2010, he testified that his alleged peripheral neuropathy began in 2003 or 2004. He described symptoms of numbness after standing for half an hour or walking two blocks. As an initial matter, the Board finds that the competent evidence of record demonstrates that the Veteran had a current diagnosis of sciatica. The Board acknowledges the November 2008 letter from the Veteran's private physician Dr. P., that peripheral neuropathy was a very common complication of diabetes and should be reconsidered, and that the Veteran's pain in his feet appeared to be related to the diabetic neuropathy. However, the Board places a higher probative value on the September 2009 VA examiner's opinion in which he reviewed the normal monofilament examination done by Dr. P. and conducted his own objective testing which also resulted in normal sensation, normal strength, normal DTR's, and muscle tone. The Board finds the more persuasive evidence indicates that the Veteran does not actually have a diagnosis of peripheral neuropathy and has not had such diagnosis at any time during the pendency of the appeal. The Board finds the September 2009 VA examiner's explanation of the bilateral lower extremity disorder to be more persuasive than Dr. P.'s November 2008 opinion that the Veteran's pain in his feet appeared to be related to diabetic neuropathy. The Board reaches this conclusion because the same objective evidence that led the September 2009 VA examiner to diagnose sciatica rather than peripheral neuropathy, is the objective testing conducted by Dr. P. that also resulted in normal findings (despite Dr. P.'s statements to the contrary). As discussed above, the Veteran claims that his bilateral lower extremity disorder is secondary to his service-connected diabetes mellitus, type II. However, the Board finds that the claim fails on a secondary basis, as the evidence does not indicate that the bilateral lower extremity disorder (sciatica) was caused or aggravated by diabetes mellitus, type II. In this regard, the Board places high probative value on the conclusion by the September 2009 VA examiner that sciatica is not known to be caused or aggravated by diabetes mellitus type II. The remaining evidence of record does not indicate that the Veteran's sciatica is caused or aggravated by his service-connected diabetes mellitus, type II. The Board has considered the Veteran's lay statements and sworn testimony from his DRO hearing, regarding his belief that his bilateral lower extremity disorder is related to his diabetes mellitus, type II. However, the Board finds that he is not competent to render an opinion diagnosing his bilateral lower extremity disorder or its etiology. See Kahana, 24 Vet.App. at 435; see also Jandreau, 492 F.3d at 1377 n.4. Although the Veteran has primarily claimed secondary service connection for his bilateral lower extremity disorder, the Board has also considered whether he is entitled to service connection on presumptive and direct bases as well. The Board finds that the preponderance of the evidence is against service connection for the bilateral lower extremity disorder, sciatica, on a presumptive basis. First, there is no evidence of sciatica within one year after the Veteran's discharge. In this regard, the absolute earliest evidence of sciatica is in 1994, which is nearly 30 years after his service discharge. Moreover, the Veteran has not alleged a continuity of bilateral lower extremity symptomatology between the time of his discharge and the diagnosis of such disease. See Walker, supra. Therefore, service connection based on the manifestation of a chronic presumptive disease within one year of service discharge is not warranted. Second, presumptive service connection based on exposure to herbicides is also not warranted. In this regard, while the Veteran served in the Republic of Vietnam during the Vietnam War and is therefore presumed to have been exposed to herbicides during service, sciatica is not a disease for which a presumption based on herbicide exposure is warranted under section 3.309(e). Significantly, in July 2009, the National Academy of Sciences (NAS) issued "Veterans and Agent Orange: Update 2008" (Update 2008). The Secretary, based upon Update 2008 and prior NAS reports, has specifically concluded that a presumption of service connection based on exposure to herbicides in the Republic of Vietnam is not warranted for sciatica. See 75 Fed. Reg. 32540 (June 10, 2008). Further, the Veteran has not been diagnosed with acute or subacute peripheral neuropathy, a disease that is listed under 38 C.F.R. § 3.309(e) for presumptive service connection. Notwithstanding the foregoing presumption provisions, the Federal Circuit Court has determined that a claimant is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). Nevertheless, the claim is also denied on a direct basis. First, there is no evidence of sciatica in service. Also, there is no history of sciatica until at least 1988, nearly 20 years after service. Such a lapse of time is a factor for consideration in deciding a service connection claim. Maxson v. Gober, 230 F.3rd 1330, 1333 (Fed. Cir. 2000). While the Veteran contends that his bilateral lower extremity disorder is related to military service (if not secondary to diabetes mellitus), the Board accords his statements regarding the etiology of this disorder little probative value as he is not competent to opine on such a complex medical question. As discussed above, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. West, 12 Vet. App. 460, 465 (1999). In this regard, the question of causation and aggravation of a bilateral lower extremity disorder involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's own opinion is nonprobative evidence. See Jandreau, supra; see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Therefore, based on the foregoing, the Board finds that service connection for a bilateral lower extremity disorder is not warranted on a presumptive, direct, or secondary basis. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for a bilateral lower extremity disorder. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. ORDER Service connection for venous stasis is denied. Service connection for hypertension is denied. Service connection for a bilateral lower extremity disorder is denied. REMAND Unfortunately, a remand is required with respect to the issues of service connection for a heart disorder and sharp pelvic pain. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran's claims so that he is afforded every possible consideration. a. Heart Disorder Regarding the claimed heart disorder, the Veteran asserts that he has "circulation problems" with prior stenting and bypass surgery. In November 2008, a private physician, Dr. P., noted that the Veteran carried a diagnosis of coronary artery disease (CAD). However, the September 2009 VA examiner diagnosed "mild aortic stenosis with no other heart condition." (emphasis added) The examiner did not explain how he reached the conclusion that the Veteran had no other heart condition besides the mild aortic stenosis. Further, it is unclear whether the examiner found that the Veteran had never had another heart condition or whether the prior CAD diagnosis had resolved prior to the September 2009 VA examination. Private treatment records dated in March 1997 demonstrate that the Veteran's cardiologist, Dr. H., arranged for the Veteran to undergo a cardiolite stress test to screen him for significant coronary artery disease. The impression following the resting electrocardiogram was a baseline normal electrocardiogram. The exercise electrocardiogram "demonstrated a normal sinus rhythm with a rate of 83." There was "normal axis and normal intervals and no significant ST/T wave changes." The impression of the post-exercise electrocardiogram was "no electrocardiographic changes consistent with ischemia seen." Further correlation was pending cardiolite stress images. A review of the images resulted in an impression of "[n]ormal persantine stress myocardial perfusion scan" and "[n]ormal left ventricular function." The September 2009 VA examiner reviewed the Veteran's history and determined that all heart testing had been benign other than his mild aortic stenosis found in 2007 after a new murmur was noted on exam. In reaching this conclusion, the VA examiner considered the Veteran's October 2007 echocardiogram, which noted the mild aortic stenosis but was otherwise benign with normal ejection fraction. The examiner also reviewed the Veteran's 1997 treatment records regarding a stress test. However, in discussion regarding the November 2008 letter from Dr. P., the September 2009 VA examiner noted that the "date of first manifestations of CAD were not provided other than an angioplasty done in February 2006." The VA examiner's statement indicates that there were manifestations of CAD. In light of the VA examiner's indication that the Veteran had manifestations of CAD, a nexus opinion should have been provided with respect to CAD. Under McClain v. Nicholson, 21 Vet. App. 319 (2007), the current disability requirement for a service connection claim is satisfied if the claimant has a disability at the time the claim is filed or during the pendency of that claim. Based on the foregoing, clarification is required from the examiner who conducted the September 2009 VA examination. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). On Remand, the examiner is asked to clarify whether the Veteran ever had a diagnosis of CAD, and if so, whether CAD was caused or aggravated by diabetes mellitus, type II. The examiner should offer an opinion even if the CAD has resolved. The examiner should also be informed that ischemic heart disease is now a disease presumptively associated with herbicide exposure. Given the Veteran's exposure to herbicides in service, if the examiner clarifies that the Veteran had a heart disorder other than mild aortic stenosis, the examiner should discuss whether such heart disorder could be characterized as ischemic heart disease. b. Sharp Pelvic Pain As an initial matter, the Board notes that the Veteran has been diagnosed with two disorders related to his sharp pelvic pain. A private treatment record dated in June 2008 diagnosed right hip osteoarthritis as the disability associated with the sharp pelvic pain. Additionally, the September 2009 VA examiner diagnosed a groin strain as the cause of the Veteran's sharp pelvic pain. Notably, the October 2008 rating decision denied a claim for service connection for a hip disability, including the right hip osteoarthritis, and the Veteran did not appeal. Thus, no further development is required regarding the right hip osteoarthritis. Regarding the currently diagnosed groin strain, the September 2009 VA examiner determined that the groin strain was not caused or aggravated by diabetes mellitus, type II. Subsequently, in an August 2010 letter received after the September 2009 VA examination report was rendered, the Veteran's private physician, Dr. L., opined that diabetes mellitus, type II "complicates his musculoskeletal pain." Dr. L. based his opinion on a medical text, MEREK MANUAL, SIXTEENTH EDITION, Chapter 10, "Musculoskeletal and Connective Tissue Disorders," page 1294, which stated as follows: All elements of the musculoskeletal system are in dynamic equilibrium, continually changing shape, structure, and function, in response to loading and mechanical demands. The system is vulnerable to trauma and peculiarly susceptible to local and systemic inflammatory disorders. Acute inflammation or tissue damage often becomes chronic, perhaps because of continuous movement and mechanical stresses. Dr. L. explained that chiropractic medicine does not diagnose or treat type II diabetes but that it does treat the musculoskeletal system that is influenced by local or systemic inflammation of the body. He noted that "Type II Diabetes by its nature, generates inflammation thus compromising the healing process." He noted that the Veteran suffers from Type II Diabetes which "complicates his musculoskeletal pain...." Given the August 2010 letter, which was received after the September 2009 VA examination and opinion, the Board finds that an addendum opinion from the September 2009 VA examiner is required to address the possibility that the Veteran's diabetes mellitus type II may aggravate his groin strain. Accordingly, the case is REMANDED for the following action: 1. Notify the Veteran that he may submit additional evidence, including any relevant treatment records, in support of his claims. Also notify the Veteran that he may identify any private physicians from whom he would like VA to request records. If he responds and identifies care providers and provides the appropriate authorization and consent, seek the records. Any negative response should be noted. 2. Following receipt of the above records, return the claims file to the September 2009 VA examiner for addendum opinions regarding the claims for service connection for a heart disorder and sharp pelvic pain. The entire claims file must be made available to the VA examiner. Pertinent documents should be reviewed. If the September 2009 VA examiner is not available, then another VA examiner should offer an addendum opinion. The Board leaves it to the examiner's discretion as to whether another examination is necessary. The examiner is asked to address the following: (a) Has the Veteran ever had a heart disorder other than mild aortic stenosis, including CAD? If not, please explain how the conclusion is reached, to include discussion of the 2006 letter from Dr. P. noting that the Veteran "carried a diagnosis of CAD." (b) If the Veteran has ever had a heart disorder other than mild aortic stenosis, could such heart disorder be characterized as ischemic heart disease? The examiner is informed that since the September 2009 VA examination report, ischemic heart disease has been named as a disease presumptively associated with herbicide exposure. (c) If the Veteran ever had a diagnosis of CAD, even if it has resolved, is it at least as likely as not (a 50 percent probability or greater) that the Veteran's CAD was caused or aggravated by the Veteran's service-connected diabetes mellitus, type II? If the examiner finds aggravation is present, the examiner should identify the baseline level of severity of the CAD prior to the onset of aggravation. If some of the increase in severity of the CAD is due to natural progress, the examiner should identify the degree of increase in severity due to natural progression. (d) Address the August 2010 letter from Dr. L. that indicates that the Veteran's musculoskeletal pain is "complicated" by diabetes mellitus, type II, and offer an addendum opinion as to whether is it at least as likely as not (a 50 percent probability or greater) that the groin strain diagnosed at the September 2009 VA examination is aggravated by the Veteran's diabetes mellitus, type II. If the examiner finds aggravation is present, the examiner should identify the baseline level of severity of the groin strain prior to the onset of aggravation. If some of the increase in severity of the groin strain is due to natural progress, the examiner should identify the degree of increase in severity due to natural progression. If the examiner determines that an additional examination of the Veteran is necessary to provide a reliable opinion as to aggravation, such examination should be scheduled. However, the Veteran should not be required to report for another examination as a matter of course, if it is not found to be necessary. A complete rationale should be given for all opinions and conclusions rendered. If the examiner is unable to offer an opinion without resort to mere speculation, the examiner is asked to state the same and explain why an opinion would require speculation. 3. Readjudicate the claims to include consideration of all evidence added to the record since the October 2011 Supplemental Statement of the Case (SSOC). If the claims remain denied, provide another SSOC to the Appellant and his representative. Return the issues to the Board for further appellate review after the Veteran and his representative have been afforded an adequate opportunity to respond to the SSOC. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ JENNIFER HWA Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs