Citation Nr: 1619001 Decision Date: 05/11/16 Archive Date: 05/19/16 DOCKET NO. 09-48 683 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Entitlement to service connection for complex regional pain syndrome (CRPS), type II, of the right lower extremity, also claimed as reflex sympathetic dystrophy (RSD) syndrome. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD S. Reed, Associate Counsel INTRODUCTION The Veteran served on active duty in Air Force from March 1975 to December 1975. This case comes before the Board of Veterans' Appeals (the Board) from a April 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. This case was previously before the Board in August 2014. The Board remanded the case to complete additional development. To the extent possible, that development has been completed. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting that where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance). The Veteran requested a hearing before the Board. A hearing was scheduled for April 2011, and the Veteran was notified of the scheduled hearing. However, the Veteran did not appear for his hearing and has not presented good cause for doing so. Therefore, his request for a hearing is considered withdrawn. 38 C.F.R. § 20.702(d) (2015). FINDING OF FACT A preponderance of the evidence indicates that it less likely as not that the Veteran's CRPS of the right lower extremity is etiologically related to his active service. CONCLUSION OF LAW The criteria for service connection for CRPS of the right lower extremity are not met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Board has reviewed the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all the evidence submitted by or on behalf of the Veteran. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (noting that the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (explaining that the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). Stegall Considerations As noted above, the Board remanded this matter in August 2014. The Board instructed the Agency of Original Jurisdiction (AOJ) to schedule the Veteran for an examination to address the etiology of his currently diagnosed CPRS of the right lower extremity. This examination was completed in November 2014 and addressed the requested issue of the etiology of the Veteran's currently diagnosed CPRS of the right lower extremity. As discussed in more detail below, this examination was adequate, and the Veteran's claim was readjudicated in a December 2014 Supplemental Statement of the Case. Thus, there has been compliance with the Board's remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Duties to Notify and Assist VA satisfied its duty to notify the Veteran pursuant to the Veterans Claims Assistance Act of 2000 (VCAA). 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), 4.2 (2015). The VCAA requires VA to assist a claimant at the time he or she files a claim for benefits. As part of this assistance, VA is required to notify claimants of the evidence that is necessary, or would be of assistance, in substantiating their claim, and provide notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. 38 U.S.C.A. § 5103(a) (West 2014); 38 C.F.R. § 3.159(b)(1) (2015); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Dingess v. Nicholson, 19 Vet. App. 473, 486 (2006). All notice under the VCAA should generally be provided prior to an initial decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). A letter from VA in October 2007 notified the Veteran of how to substantiate his service connection claim. The letter notified the Veteran of the allocation of responsibilities between himself and VA, and of how ratings and effective dates are assigned. Therefore, the duty to notify is satisfied. VA's duty to assist under the VCAA includes helping the claimant obtain service treatment records (STRs) and other pertinent records, as well as performing an examination or obtaining a medical opinion when one is necessary to make a decision on the claim. See 38 U.S.C.A. § 5103A (West 2014); 38 C.F.R. § 3.159(c) (2015). Here, the Veteran's service treatment records, private treatment records, and VA medical records are associated with the Veteran's claims file. Therefore, the VA's actions satisfied its duty to assist the Veteran in developing his claim. See 38 U.S.C.A. § 3.159(e) (West 2014). The Veteran was afforded a VA examination in November 2014 to assess the nature and relationship of the Veteran's CPRS of the lower right extremity to his active duty service in accordance with McLendon v. Nicholson, 20 Vet. App. 79 (2006). The examiner took an occupational and medical history from the Veteran, reviewed the Veteran's medical records, and conducted a physical examination. Based on the examination and medical history the examiner concluded the Veteran's CRPS of the lower right leg was less likely than not caused by or a result of or etiologically related to active duty military service. The examiner supported this opinion by stating the Veteran's STRs were silent for symptoms or a diagnosis of the claimed condition; that after service, the records are silent for the claimed condition until 1994; and there is clear documentation that the claimed condition occurred after and was secondary to severe trauma to the Veteran's right leg and ankle in 1994. The Veteran contended in the March 2016 Appellate Brief, that the examination was inadequate. Specifically, he argued that the examiner's opinion is inaccurate because it stated that the Veteran's STRs are "silent for symptoms of/diagnosis of this [claimed] condition;" whereas the STRs noted in-service complaints of right leg, ankle, and foot pain. This argument presumes that the type of pain that was reported in the STRs is a symptom of CRPS or RSD. Neither the Veteran nor his representative have demonstrated they have the expertise or training to competently opine such a fact. On the other hand, the examiner is competent to opine on this issue, and did so in his report. The examiner noted in detail the Veteran's complaints of right leg pain in the STRs and wrote a comment that reads, "this symptomatology at separation is consistent with recent [gunshot wound] injury to gastrosoleus muscle and sural nerve on the right, and acute right Achilles tendonitis, and was not reflex sympathetic dystrophy or complex regional pain syndrome." The Board notes that in a September 1992 rating decision, service connection for a gunshot wound of the right thigh was denied. Reading the VA examination report as a whole and in the context of the evidence, the Board finds the examination and accompanying opinion were adequate. See Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (finding medical reports must be read as a whole and in the context of the evidence of record); Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (noting the fact that the rationale provided by an examiner "did not explicitly lay out the examiner's journey from the facts to a conclusion," did not render the examination inadequate). Therefore, there is sufficient evidence to decide this claim, and further medical opinion is not necessary to decide the claim for an increased initial rating for the Veteran's CRPS. See 38 U.S.C.A. § 5103A(d) (West 2014); 38 C.F.R. § 3.159(c)(4) (2015). The Veteran requested a hearing before a Veteran's Law Judge, but constructively withdrew that request as he did not appear for the hearing without providing good cause. See 38 C.F.R. §20.702(d) (2015). All appropriate due process concerns have been satisfied. See 38 C.F.R. § 3.103 (2015). The Veteran has been afforded the opportunity to present evidence and argument in support of his claim. Accordingly, the Board will proceed to a decision as to the issue on appeal. Legal Criteria To establish a right to compensation for a present disability on a direct basis, a Veteran must show: (1) evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C.A. § 1131 (West 2014). That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b) (2015). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d) (2015). Analysis In the present case, the Veteran has shown that the first and second Hickson elements have been met. The November 2014 VA examination as well as the Veteran's private medical records indicate the current diagnosis of CRPS of the right lower extremity. Further, the Veteran's STRs indicate that he experienced pain in the right lower extremity which resulted in the placement and subsequent removal of a short leg walking cast that was too tight. These records establish a present disability and an in-service injury. See Hickson v. West, 12 Vet. App. 247, 253 (1999). Therefore, the pertinent discussion in this case focuses on the third Hickson element, a nexus between the in-service injury and the current disability. The preponderance of the evidence shows there is not a nexus between the Veteran's in-service injury and his current CRPS of the right lower extremity. The Veteran has asserted in his May 2007 and November 2007 statements in support of the claim as well as in his May 2008 notice of disagreement that his current CRPS is a direct result of the placement of a cast on his right leg that was too tight. While the Veteran is competent to testify to the events he experienced, he is not competent to opine the etiology of his CRPS because he does not have specialized training or experience on the subject. As noted above, the VA medical examiner opined that this event was less likely than not related to or the cause of the Veteran's current CRPS of the lower right leg. Further support of the examiner's opinion is found in the Veteran's private treatment records. The Veteran's pain management specialist for his CRPS, Dr. DHE, consistently noted that the Veteran's CRPS occurred after a traumatic injury in 1994. The Veteran pointed to a letter from Dr. DHE that he said supported his claim that the in-service cast, which was too tight, resulted in his current CRPS; however, Dr. DHE's letter does not state such an opinion. Instead, the letter from March 1997 states that the Veteran's CRPS of the right lower extremity is from a traumatic jury which occurred in the fall of 1994. Therefore, a preponderance of the evidence shows that there is no nexus between the Veteran's in-service injury and present CRPS of the right lower leg. Additionally, the Board notes, as did the November 2014 VA examiner, that the evidence does not establish chronicity and continuity of symptoms. The Veteran was not diagnosed with CRPS until 1995 and showed no symptoms until after a traumatic accident in 1994. Records from 1986 through 1994 were silent to the condition, and there are no records from the Veteran's separation from service in 1975 through 1986. Moreover, the Veteran's own statement when seeking treatment indicated that he did not have symptoms until after 1994. Specifically, the October 2007 records from the Panama City Outpatient Clinic noted the Veteran reported he has had pain in his lower right leg for the past 12-14 years. This is chronologically consistent with the medical records that indicated his CRPS of the right lower extremity occurred as a result of an accident in 1994. To the extent that he has reported pain in the leg after separation from service and prior to 1994, the Board finds that assertion is not credible. Therefore, the evidence does not support a nexus via chronicity and continuity of symptomatology. See 38 C.F.R. § 3.303(b) (2015). Accordingly, the preponderance of the evidence does not support service connection for the Veteran's CRPS of the lower right leg because there is no nexus between an in-service injury and the current disability ORDER Entitlement to service connection for CRPS of the lower right extremity is denied. ____________________________________________ K. J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs