Citation Nr: 18143888 Decision Date: 10/22/18 Archive Date: 10/22/18 DOCKET NO. 11-11 738 DATE: October 22, 2018 ORDER Entitlement to service connection for peripheral vascular disease (also claimed as peripheral arterial disease (PAD)) of the bilateral lower extremities is granted. Entitlement to service connection for a disorder manifested by numbness of the hands and feet, to include as secondary to peripheral vascular disease is granted. Entitlement to service connection for hypertension, to include as secondary to peripheral vascular disease is granted. FINDINGS OF FACT 1. The Veteran’s peripheral vascular disease or PAD is reasonably shown to have had its onset in service and to have persisted since. 2. The evidence reasonably shows that the Veteran has a disorder manifested by numbness of the hands and feet which is related to his service-connected peripheral vascular disease or PAD. 3. The evidence reasonably shows that the Veteran has hypertension which is related to his service-connected peripheral vascular disease or PAD. CONCLUSIONS OF LAW 1. The criteria for service connection for peripheral vascular disease of the bilateral lower extremities or PAD have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 2. The criteria for service connection for a disorder manifested by numbness of the hands and feet, to include as secondary to service-connected peripheral vascular disease or PAD have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. 3. The criteria for service connection for hypertension, to include as secondary to service-connected peripheral vascular disease or PAD have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Army from October 1989 to July 1993, and from January 1995 to January 1998. He also served in Southwest Asia from December 1990 to May 1991. In November 1999 the Veteran was notified of an October 1999 rating decision that, in pertinent part, denied service connection for a disorder manifested by numbness of the hands and feet because the claim was not well grounded. That decision reportedly noted that the available service treatment records (STRs) of both periods of service were negative for numbness of the hands and feet and VA examination in November 1998 was also negative. In light of the enactment of the Veterans Claims Assistance Act (VCAA) of 2000, which eliminated the concept of a well-grounded claim, the claim for service connection for a disorder manifested by numbness of the hands and feet was readjudicated on the merits in February 2002 and the Veteran was notified by letter of that same month that the claim was denied. That decision again noted that the STRs were negative and the September 1997 separation examination was negative for any complaint of numbness and he likewise had no complaint of numbness on VA examination in November 1998. The Veteran applied to reopen that claim, and also claimed service connection for hypertension and peripheral vascular disease of the lower extremities in April 2009. A November 2009 Memorandum determined that the STRs of the Veteran’s first period of service were unavailable for review, and the steps taken to obtain them were set forth. It was found that all efforts to obtain the information had been exhausted, that further attempts would be futile, and that the records were not available. However, since the 2002 rating decision the Veteran has submitted copies of additional STRs of his first period of military service. Regulations provide that, at any time after VA issues a decision on a claim, if VA receives or associates with the claims file relevant official service department records that existed and had not been associated with the claims file when VA first decided the claim, VA will reconsider the claim. The regulation further identifies service records related to a claimed in-service event, injury, or disease as relevant service department records. 38 C.F.R. § 3.156(c)(1)(i). As such, new and material evidence is not needed to reopen a previously denied claim when relevant STRs and/or any other relevant service department records are received after a prior final denial. In the instant case, the newly received STRs were relevant to the claim for service connection for a disorder manifested by numbness of the hands and feet. This matter was addressed at the January 2013 videoconference. (See pages 23 and 24 of the transcript thereof.) Thus, the Board found that such STRS fall within the scope of 38 C.F.R. § 3.156(c)(1)(i). Therefore, the claim for service connection for a disorder manifested by numbness of the hands and feet will be addressed on a de novo basis. Service Connection Service connection may be granted for disabilities due to disease or injury incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. However, service connection may also be granted for any disease initially diagnosed after discharge when the evidence establishes that disability was incurred in service, or by showing continuity of symptoms after discharge. 38 C.F.R. § 3.303 (b)(d). Secondary service connection may be established for a disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310 (a); see also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). To substantiate a secondary service connection claim, the Veteran must show: (1) a present disability (for which service connection is sought); (2) a service-connected disability; and (3) competent evidence that the service connected disability caused or aggravated the disability for which service connection is sought. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. The Veteran’s STRs show that an October 1989 medical history questionnaire in conjunction with entrance into the Veteran’s first period of service reflects that the Veteran did not report having or having had any pertinent abnormality. An undated STR shows that the Veteran was given an injection of some kind of medication into his right gluteal muscle. In October 1991 the Veteran complained that his leg would give out when he used it a lot and it would be painful. On examination he had slight swelling of the leg. It was noted that his complaint of pain was of the left knee. The relevant assessment was knee pain. In January 1992 the Veteran had headaches and dizziness upon awakening and was unable to hold down fluids. He had had diarrhea and vomiting. His blood pressure readings were 140/80, 150/88, and 120/90 (otherwise all blood pressure readings during his first period of service were within normal limits). After an examination the assessment was that he had a viral syndrome. In January 1992 the Veteran was seen for a follow-up for a viral syndrome. The assessment was a viral syndrome. He was seen in February 1992 for a marriage physical and it was noted that he had no history of coronary artery disease (CAD), hypertension (HTN), or diabetes. In January 1993 the Veteran presented complaining of having had knots on both shins for one year. The knots would come and go. He stated that the knots appeared after running and would last for 1 or 2 days. He also stated that his right foot would become numb when running. He currently had no knots but was instructed to return to the clinic following a run if knots were present. He also complained of paresthesia of the right foot. On examination deep tendon reflexes (DTRs) were 2/2 and muscle strength was 5/5. Capillary refill to the nail beds was less than 2 seconds. Temperatures of the feet were equal. He had trouble distinguishing between sharp and dull sensation across the dorsum of the foot. The assessment was post paresthesia. A neurology consult was recommended. Received from the Veteran in November 1993 was a report of a March 1993 chest X-ray which revealed the cardiac silhouette and great vessels were within normal limits. Received from the Veteran in November 1993 was a report of a periodic examination for the Army National Guard (between his two periods of active service). This examination found that pedal and posterior tibial pulses were 2+ bilaterally, and that capillary refill took 3 seconds. His blood pressure was 135/82. In an adjunct medical history questionnaire, he reported having or having had “high or low blood pressure,” cramps in his legs, and foot trouble. It was observed that he had no blood pressure problems at present. His feet would become numb with running or he would have leg cramps. The report of the August 1994 examination for enlistment into the Veteran’s second period of service found no pertinent abnormality, and he had no pertinent complaints in an adjunct medical history questionnaire. All blood pressure readings during his second period of service were within normal limits. A February 1995 STR record reflects that the Veteran’s blood pressure was 130/72, but it was noted that he had a family history of high blood pressure. The report of examination in September 1997 for separation from the Veteran’s second period of service noted that he had a probable ganglion cyst of the proximal interphalangeal (PIP) joint of the index finger of the “left” hand, and he had decreased capillary refill of both lower extremities which caused decreased sensation to cold. It was noted that while he was, overall, healthy, he had decreased circulation in both lower extremities, and a ganglion cyst of the “right” index finger. He was to seek consultation with Internal Medicine for further evaluation of “Gulf War Syndrome.” In an adjunct medical history questionnaire, the Veteran complained of having or having had swollen or painful joints; frequent or severe headaches; shortness of breath; palpitation or pounding heart; and foot trouble. He reported that both feet would give out when running and he would have no feeling in the right foot. It was noted that he had not had any specific injuries of the knees or feet but claimed to have pain after running and had been told he had shin splints and poor circulation. He had had unexplained headaches for the last 3 to 4 years which were relieved with sleep or Tylenol. He had some respiratory complaints and cramps in his legs when running but the cramps could occur at other times. An October 1997 STR record reflects that the Veteran’s blood pressure was 146/86. On VA neurology examination in November 1998 the Veteran’s pertinent complaint was of “problems with his limbs” but when asked about numbness of his hands and feet, he denied ever having had numbness. He stated that in 1991 he began having various aches and pains in his body which had been persistent for the last 4 years. He reported that when he walked his feet gave out. He complained of leg stiffness but again reported not having numbness or losses of sensation. A neurological examination was normal and, specifically, DTRs were symmetrical and normoactive. Sensory testing was normal. There was no pertinent diagnosis and no etiological opinions were provided. On VA general medical examination in November 1998 the Veteran reported that beginning in and since service he had had a cough, low back pain, and that in 1992 he began having problems with pain in his feet. He was worried that he might have diabetes or poor circulation, or some problem of that nature. On examination his blood pressure was 118/76. His heart was not enlarged and his pulses were normal in rate and rhythm. There were no varicosities and peripheral vessels were normal. He reported that his feet had also hurt him since 1992. The examiner stated that this probably represented plantar fasciitis. The diagnoses included bilateral plantar fasciitis. X-rays of all spinal segments, both wrists, both feet, and both knees were normal. No etiological opinions were provided. VA outpatient treatment (VAOPT) records of 1999 show that in February 1999, when evaluated for low back pain of 2 months duration, the Veteran’s blood pressure was 152/84. A VA Persian Gulf examination in March 1999 noted the Veteran’s complaint of intermittent twitching of the right hand since January 1994 with weakness but no numbness. He reported having had numbness and weakness of the feet since March 1992 which was intermittent and usually occurred after walking one or more miles, accompanied by a tingling of the bottom of his feet. No etiological opinions were provided. VAOPT records show that in February 2000 the Veteran complained of mid-epigastric chest pain. His blood pressure was 133/98. The assessment was atypical chest pain, possibly cardiac. In April 2000 his blood pressure was 138/82 and he complained of muscle spasms throughout his body. He also complained of numbness in his legs. The assessment was muscle spasms. VAOPT records show that in January 2006 it was noted that an EKG revealed “LVH (left ventricular hypertrophy) type changes” but the Veteran had no history of hypertension. He was to be re-checked in 6 weeks for any borderline blood pressure readings and it was noted that he had once had an elevated systolic reading in January 2005. A January 2008 VAOPT record shows that the Veteran reported that he was told he had elevated blood pressure on an employment physical. He also complained of poor circulation in his arms and legs. Also in that same month it was noted that he had always felt he had some problem with circulation but he denied any history of claudication and mainly described feelings of his legs becoming numb if he sat for ½ hour or more. He had never had any exercise related symptoms. He had no history of a back injury. A 2001 EMG and a 2007 spinal MRI were negative for any pathological explanations. An examination revealed no neurological or circulatory abnormality of either upper or either lower extremity. The assessment was probable non-specific somatic symptoms which the Veteran incorrectly described as a circulation problem. However, if it helped to satisfy him, an arterial doppler study could be performed. An abdominal aorta and bilateral lower extremity run-off examination in April 2009 from Carolina Imaging shows that the study was done for possible left common iliac artery occlusion, and it found atherosclerotic plaque in the distal abdominal aorta extending into the right and left common iliac arteries, with 70 percent stenosis of the distal right common iliac artery. An abdominal and pelvic CT scan in April 2008 revealed apparent occlusion of the left common iliac artery. Correlation with clinical symptoms of possible buttock claudication was recommended. An April 2009 VAOPT record shows that the Veteran had a 10-year history of leg pain and numbness with ambulation. After an examination the impressions were claudication and extensive peripheral arterial disease. It was noted that this was very unusual in a young person and had been an issue for at least 10 years. A May 2009 VAOPT record indicates that the Veteran had peripheral vascular disease and claudication since military service in 1998. It was also noted that he had anxiety with muscle spasms of the large muscles of the arms and legs for years, which came and went with stress. Records of Northside Urgent Care include a June 2009 statement from Dr. Ferguson reflecting that the Veteran had been on Worker’s compensation. He had been seen in March 2009 complaining of abdominal pain and a CT revealed left common iliac artery occlusion. In statements in July and August 2009 the Veteran reported that when discharged from service in 1998 he had had pain in his hips and numbness of his hands and feet. VA treatment records show that in September 2009 it was noted that the Veteran had had: “an Aortoiliac bypass at Duke in June. Has had elevated BP and headaches since then he feels. Has been taking meds regularly. BP checked at Durham VA in August was high ‘but not as high as today.’” Additional VA treatment records show that in September 2009 the Veteran reported having had headaches since his aortofemoral bypass in June 2009. He stated that a nurse at his place of employment had checked his blood pressure and found it to be severely elevated. A VAOPT record in September 2009 noted that it was unclear if the Veteran’s headaches were due to high blood pressure or to stress, or both. In December 2009 the Veteran’s claims files and medical records were reviewed by a physician’s assistant. He had had bilateral femoral bypass grafting in June 2009 and since that surgery he had had numbness of above each knee to the hips, which a surgeon had told him was a known complication of the surgery. The diagnosis was peripheral vascular disease of the bilateral lower extremities, status post aorto-bifemoral bypass. No opinion was provided as to the etiology or onset of the disease. In February 2010 the Veteran’s claims files and medical records were reviewed by a physician. The findings by the physician’s assistant in December 2009 were repeated. It was opined that the Veteran’s peripheral vascular disease less likely than not to have had its onset during service. The rationale was that an isolated decreased capillary refill at the time of the exit examination and associated cold extremities objectively, in the absence of symptoms during military service, which would be expected to include claudication-like symptoms and/or difficulty performing physical training, it would be difficult to attribute to peripheral vascular disease to a time eleven (11) years prior to vascular surgery. Further, there was an absence of continuity between the time in the military and the diagnosis in 2009. On VA examination in February 2010 to evaluate the severity of the Veteran’s service-connected PTSD it was reported that psychological testing found no evidence of over-reporting of symptoms or complaints. VA treatment records show that in February 2011 it was noted on an examination for evaluation whether the Veteran had PTSD that: “Findings from psychological tests measuring problems other than PTSD: Veteran produced a valid PAI clinical profile, with no evidence of over-reporting symptoms or complaints.” Additional VA treatment records, also show that in February 2012 it was noted that: “Vascular conditions, Veteran began having bilateral lower extremity, weakness, numbness, cramping as early as 1992. He reported to Fayetteville VAMC for the first time in 1998. There were some delays but diagnosis of occlusive vascular disease was made in 2000 after CT evaluation. [vascular consult note is pertinent--- ‘This is very unusual in a young man, and has been an issue for at least 10 years. I spoke with Dr. Turley of surgery, and he spoke with Mr. [redacted]. Given he has no rest pain or signs of acute arterial occlusion, he can be followed as an outpatient. We arranged follow-up on 4/30 in the vascular surgery clinic. -- In the meantime, he is to obtain his CD from the CT angiogram, we will get an ABI here, and he is to return if any symptoms of acute occlusion develop.’]” VA treatment records show that in June 2012 it was noted that since the Veteran’s aorto-bifemoral bypass in 2009 his symptoms had much improved but had not entirely resolved. At the January 2013 videoconference the Veteran testified that he had numbness in the hands and feet, and cramping in his legs, during service when he ran and performed physical training. (Page 4 of the transcript.) This started in 1991, during his first period of active duty, and he had gone on sick call. At that time there had been a notation of his having leg cramps. He had gone on sick call on several occasions. His service records showed that he had had a complete physical performed in 1989 which included checking his upper and lower extremities, and even checked his fingernails to see if his circulation was satisfactory. (Page 5.) At that time the examination was normal. He had gone on sick call for these symptoms during both periods of active duty and at the examination for separation from his second period of service it was noted that he had cramps in his legs and had “decreased capillary refill” or problems with circulation in his legs. (Pages 6 and 7.) These symptoms continued after his second period of active service. At separation from his second period of service he was told to seek follow-up with VA, which he did at the VA in Fayetteville in 1999. (Page 8.) He had been hospitalized at VA in 2000 not long after military service, because it was thought he had arthritis in his spine but at that time he also had cramping and numbness in his feet. (Pages 7 and 8.) Upon discharge from that period of hospitalization the diagnoses were GERD but he was told that the cause of the numbness of his feet could not be identified. Nevertheless, his symptoms increased over the years. (Page 8.) The Veteran testified that while working for a tile company in 2009, performing extensive physical work, his blood pressure had increased and he was evaluated by a physician’s assistant at that company who had advised him to seek an outside medical evaluation, and that evaluation had revealed that he had high blood pressure. At that time, he was still having pain in his hips and the same numbness. (Page 9.) He had then seen Dr. Ferguson, a retired Flight surgeon, who placed the Veteran on anti-hypertensive medication in June 2009. However, the Veteran’s blood pressure remained high despite the medication. He was then scheduled for an “arteriogram CAT scan” which had revealed blocked arteries that Dr. Ferguson said VA had missed. He then had by-pass graft surgery at the “Duke Medical Center VA.” (Pages 10 and 11.) This had been in 2009, and he had also had two stents inserted in the groin area but had still had to have by-pass graft surgery. He still had cramping of his legs and numbness of the feet because of impaired circulation. (Page 12.) The impaired circulation also affected his upper extremities. (Page 13.) He was now treated at the Durham VA medical facility and took multiple cardiovascular medications. He contended that the numbness of his hands and feet during service was an early manifestation of his current arteriosclerosis. (Page 14.) He contended, and his physician had informed him, that his hypertension was due to the arteriosclerosis. (Pages 15 and 16.) The Veteran testified that his wife was a registered nurse. (Page 11.) She testified that they were married in 1999, not long after his discharge from his second period of service. She had been a registered nurse for 25 to 26 years. She recalled his having had muscle spasms of the upper and lower extremities when they got married. (Pages 17 and 18.) The Veteran’s physician had briefed her on the Veteran’s condition and informed her that stents were to be placed in the Veteran due to circulatory blockages but because the occlusions were so vast the stent could not be inserted and by-pass grafting had to be done. (Page 18.) She had been told that the Veteran had developed collateral circulation, which was building blood vessels around a blockage, which took years to develop and had it not been for this collateral circulation the Veteran might have lost his legs. (Page 19.) She testified that her primary specialty was working in a “medical-surgical unit” which specialized in “strokes and heart care, cardiac care.” (Page 20.) The Veteran’s representative stated that the last VA examination which the Veteran had been given was in 2009 yielded an opinion which was negative, but the opinion was inadequate because no rationale was given. (Page 21.) The Veteran indicated that he was willing to attend another VA examination. Also, the Veteran conceded that there was nothing in the STRs indicating that he had hypertension. (Page 22.) Because originals of his STRs of his first period of active duty were not in his claims files, he had submitted copies of such records which showed that his symptoms began in 1990, during his first period of service. (Page 23.) In an October 2013 statement the Veteran asserted that his peripheral vascular disease was a cardiovascular disease which was listed as an undiagnosed illness pertaining to the Gulf War Illnesses and that he was a Gulf War veteran. In March 2015, the Veteran underwent hypertension, artery and vein, and foot conditions examinations. During the Hypertension examination, the examiner noted that the Veteran had a diagnosis of hypertension from 2009 and that he had been on continuous medication. The Veteran’s blood pressure readings were 162/96, 163/96, and 154/91. The examiner opined that after reviewing the Veteran’s records and the medical literature that PVD does not cause or aggravate hypertension but that hypertension is a risk factor for the development of PVD. During the Artery and Vein Conditions examination, the examiner noted that the Veteran had a diagnosis of PVD, bilateral lower extremities from 2009. The examiner noted that the Veteran reported that his symptoms began in October 1991 despite not being diagnosed until 2009. The examiner noted that the Veteran had been diagnosed with peripheral vascular disease as well as arteriosclerosis obliterans and had undergone an aortofemoral bypass in June 2009. The examiner noted claudification on walking in both legs. The examiner opined that the condition claimed was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The examiner provided the rationale that the Veteran was found to have decreased capillary filling of the lower extremity on his exit exam in September 1997 and decreased cold sensation as well. That it was well documented that the Veteran had a long history of smoking, elevated cholesterol and significant history of ethanol abuse all of which were contributors to vascular disease to include peripheral vascular disease. During the Foot Conditions examination, the examiner provided no responses to any questions. However, he opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The examiner provided the rationale that on the Veteran’s exit exam in September 1997 there was no mention of upper extremity numbness or other vascular conditions. The examiner noted that this was the only documentation found in the STRs or other documents until the diagnosis of PVD in 2009. Furthermore, the examiner again noted the Veteran’s history of smoking, elevated cholesterol and significant history of alcohol abuse all of which he noted were contributing factors to vascular disease. In May 2018 a VHA outside medical opinion was obtained. The cardiologist who rendered the opinion found that he believed that the Veteran’s peripheral vascular disease or peripheral arterial disease (PAD) began during his active duty service. The examiner provided the rationale that the Veteran complained over multiple occasions of leg symptoms and that the September 1997 exam clearly documented decreased capillary refill. Furthermore, he noted that the Veteran reported symptoms after running in 1993. The examiner noted that the Veteran’s is an unusual case of premature PAD, which he suspected the Veteran had lower extremity symptoms due to very premature PAD which was undiagnosed until it progressed. He noted that the Veteran’s level of disease was very proximal and that it was not unusual for patients with such to go undiagnosed for long periods of time as their peripheral pulses may seem intact on exam. The examiner further noted that after a review of the Veteran’s records, while he had only random elevated blood pressure readings during service, and that his hypertension diagnosis was not made until later, that hypertension is a known risk factor for PAD. He opined that there was more than a 50 percent probability that the Veteran’s hypertension was aggravated by his premature vascular atherosclerosis or PAD. In addition, the examiner opined as to the Veteran’s claimed condition which manifested as numbness of the hands and feet that he could not comment on hand numbness symptoms as he could not find an upper extremity vascular evaluation, but that the Veteran’s feet numbness was probably related to his premature PAD and possibly aggravated by such. Entitlement to service connection for peripheral vascular disease of the bilateral lower extremities or PAD. The Veteran reports that he has peripheral vascular disease or PAD that began in service and persisted thereafter. The medical evidence is not in dispute as to whether the Veteran has current peripheral vascular disease-in fact, the significant clinical diagnoses in the record indicate peripheral vascular disease, atherosclerosis and PAD. In addition, the Veteran is fully competent to report lay-observable symptoms (such as leg pain and cramps) and describe their history, course, and progression, and the Board has found no reason to question the veracity of his various statements espousing continuous leg cramps beginning in and continuing since service. They have been largely consistent and are not directly refuted by any other evidence, including medical evidence. Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (finding credibility can be generally evaluated by facial plausibility of the testimony and the consistency of the witness testimony). Critically, the Board notes that the most probative linkage opinion in the record (from the May 2018 VHA cardiologist) found that the Veteran’s peripheral vascular disease or PAD began during his active duty service, but was likely undiagnosed as it was an unusual/rare case. The Board finds the May 2018 opinion highly probative. In so finding, the Board acknowledges that the March 2015 and February 2010 examiners found no relationship between the Veteran’s current peripheral vascular disease or PVD and his active duty service. Furthermore, the Board also notes that while the November 1998 examiner provided no etiological opinion, he did note that the Veteran’s pedal pulses, rate and rhythm were all normal. However, the May 2018 examiner noted that in cases such as the Veteran’s pedal pulses may appear normal due his proximal symptoms. Furthermore, the February 2010 examination appears to be based on inaccurate or incomplete information, as the examiner stated that there was an absence of claudication-like symptoms during service and/or difficulty performing physical training which made it difficult to attribute the Veteran’s PVD to military service. However, the Veteran reported having had exercise related complaints in October 1991 and again in January 1993 during his first period of service, and exercise related symptoms were reported in the medical history questionnaire at the time of his discharge from his second period of service. Finally, the Board finds that the March 2015 opinion is based on insufficient rationale. The examiner stated that the Veteran had decreased capillary filing of the lower extremities at the time of his exit exam and that he had decreased cold sensation. The examiner also stated that the Veteran had a history of smoking, elevated cholesterol and history of alcohol abuse which are all contributing factors to PVD. However, the examiner did not explain how any of his observations supported his conclusion. In light of the above, the Board finds that the evidence is at least in relative equipoise as to whether the Veteran’s current peripheral vascular disease or PAD began in, has been continuous since, or is otherwise related to, service. Resolving all remaining reasonable doubt in the Veteran’s favor, the Board finds that service connection for peripheral vascular disease or PAD is warranted, and the appeal in this matter must be granted. Entitlement to service connection for a disorder manifested by numbness of the hands and feet, to include as secondary to peripheral vascular disease. As noted above, to substantiate a claim of service connection, there must be evidence of: (1) a current disability (for which service connection is sought); (2) incurrence or aggravation of a disease or injury in service; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-1167 (Fed. Cir. 2004). Secondary service connection may be established for a disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310 (a); see also Allen, 7 Vet. App. at 439 (en banc). To substantiate a secondary service connection claim, the Veteran must show: (1) a present disability (for which service connection is sought); (2) a service-connected disability; and (3) competent evidence that the service connected disability caused or aggravated the disability for which service connection is sought. The Veteran contends that he has a disorder manifested by numbness of the hands and feet, which is the result of his active duty service or in the alternative is secondary to his service-connected peripheral vascular disease. At the outset, the Board finds the evidence clearly establishes a current disorder manifested by numbness of the hands and feet, as the Veteran has repeatedly reported such throughout his appeal and medical history. In addition, although there is no evidence of such in service, he is service-connected for peripheral vascular disease or PAD which he asserts has caused or aggravated his current disorder manifested by numbness of the hands and feet. Thus, what must be shown to establish his claim is that the two disabilities are medically related. Whether such a relationship exists is a medical determination beyond the scope of lay observation. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (2007). Here, there are two conflicting medical opinions in the record. However, as the March 2015 negative VA opinion is not supported by a sufficient rationale, as the examiner merely stated that there was no mention of upper extremity numbness or other vascular conditions at the Veteran’s exit examination or until his PVD diagnosis in 2009. And as the examiner did not discuss the theory of secondary service connection, let alone the idea that the Veteran’s PVD aggravated his claimed disorder manifested as numbness in the hands and feet, the Board affords it no probative weight. In contrast, the May 2018 VHA examiner stated after a thorough review of the Veteran’s records that his condition was probably related to his premature peripheral arterial disease and possibly aggravated by such. Accordingly, the Board finds that the evidence is at least in relative equipoise as to whether the Veteran’s disorder manifested by numbness of the hands and feet is related to his service-connected peripheral vascular disease or PAD. Consequently, service connection for a disorder manifested by numbness of the hands and feet (as secondary to his peripheral vascular disease or PAD) is warranted. Entitlement to service connection for hypertension, to include as secondary to peripheral vascular disease. The Veteran contends that he has hypertension as a result of his service, or in the alternative as a result of his service-connected peripheral vascular disease or PAD. At the outset, the Board finds the evidence clearly establishes current hypertension. In addition, although there is no evidence of hypertension in service, he is service-connected for peripheral vascular disease or PAD which he asserts has caused or aggravated his current hypertension. Thus, what must be shown to establish his claim is that the two disabilities are medically related. Whether such a relationship exists is a medical determination beyond the scope of lay observation. Jandreau, 492 F.3d at 1377. Here, there are two conflicting medical opinions in the record. However, as the March 2015 negative VA opinion is based on insufficient rationale, the Board finds it is entitled to less probative weight. The March 2015 examiner merely stated his conclusion and noted that PVD does not cause or aggravate hypertension but that hypertension is a risk factor for the development of PVD. In contrast, the May 2018 VHA examiner, noted that after a thorough review of the Veteran’s records, while he only had random elevated blood pressure readings in service, and that hypertension is a known risk factor for PAD, the examiner believed that the Veteran’s premature vascular atherosclerosis (PAD) aggravated his hypertension. Therefore, the Board affords the May 2018 opinion greater probative weight. Accordingly, the Board finds that the evidence is at least in relative equipoise as to whether the Veteran’s hypertension is related to his service-connected peripheral   vascular disease or PAD. Consequently, service connection for hypertension (as secondary to his peripheral vascular disease or PAD) is warranted. L. M. BARNARD Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Unger, Associate Counsel