Citation Nr: 18144051 Decision Date: 10/23/18 Archive Date: 10/23/18 DOCKET NO. 16-30 369 DATE: October 23, 2018 ORDER Entitlement to service connection for a right leg condition, claimed as radiculopathy but manifesting as residuals of a right hamstring injury (hereafter referred to simply as a “right leg condition”), is granted. FINDING OF FACT The Veteran’s right leg condition began during active service. CONCLUSION OF LAW The criteria for service connection for a right leg condition are met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active duty service from October 2010 to October 2015. This case is on appeal before the Board of Veterans’ Appeals (Board) from a February 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Paul, Minnesota. The Veteran initially filed a claim for service connection for radiculopathy of the right leg. However, in Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), the United States Court of Appeals for Veterans Claims held that the Board should consider claims as affecting general parts of the body as described by the veteran rather than particular diagnoses. Accordingly, the Board has re-characterized the issue as shown on the title page. As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a). The Board herein grants in full the benefit sought on appeal. Accordingly, assuming, without deciding, that any error was committed with respect to either the duty to notify or the duty to assist, such error was harmless and will not be discussed. The Veteran asserts that the VA has not properly evaluated his right leg condition. He claims to have experienced radiating pain during service, and exhibits current complaints of lower back pain radiating down his right lower extremity to his knee and ankle. The Veteran also alleges that his doctors have verified the existence of radiating nerve pain related to injuries incurred in service. See February 2016 correspondence. Service connection means that the facts establish that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). To establish service connection for a disability, there generally must be (1) medical evidence of a current disability, (2) medical evidence, or in certain circumstances lay testimony, of in-service incurrence or aggravation of an injury or disease, and (3) medical evidence of a nexus between the current disability and the in-service disease or injury. Hickson v. West, 12 Vet. App. 247 (1999). Additionally, service connection may be established for any disease diagnosed after discharge when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt is given to the Veteran. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). As such, the Veteran prevails when the evidence supports his claim or is in relative equipoise but does not prevail when the preponderance of the evidence is against the claim. Id. The Veteran’s service treatment records reveal numerous injuries to his right lower extremity. A treatment record from October 2012 noted a past hamstring injury, while an MRI of the Veteran’s right thigh from that same month showed a long head tear of his biceps femoris. However, during follow-up appointments through February 2013, the Veteran denied numbness and tingling in his right lower extremity. Similarly, the Veteran denied back pain, numbness, and tingling during his March 2015 separation examination. The Veteran was afforded a VA examination in November 2015. He was diagnosed with lumbosacral strain resulting from a tear of his right biceps femoris. The Veteran stated that flare-ups of pain occurred with the same frequency, but indicated that the intensity had gotten worse over time. Nonetheless, the examiner found no evidence of any neurological condition. In December 2015, the Veteran sought treatment for complaints of lower back pain with radiation to the right hamstring area. The attending physician noted the Veteran’s history of a right hamstring injury, stating that his complaints were likely related to this condition since there was no new injury. The attending physician went on say that this is the area where body armor would hit, and that he suspected these complaints were related to the Veteran’s deployment. Although an X-ray of the Veteran’s lumbar spine revealed slight anterior wedging at the T2 joint, the disc spaces were well-preserved and there was no evidence of significant osteophytosis, or acute fractures or dislocations. The findings were described as “essentially negative.” The Veteran underwent a second VA examination in December 2015. The examiner reviewed the claims file, and opined that the Veteran’s alleged radiculopathy is not the result of his military service. The examiner noted the Veteran’s right hamstring tear, but found no evidence of a thoracolumbar condition. Indeed, the examiner explained that there was no evidence of nerve root impingement or objective nerve involvement despite the Veteran’s subjective complaints. As such, the examiner concluded that the pain in the Veteran’s right lower extremity stems from his hamstring injury rather than an underlying neurological condition. In January 2016, the Veteran reported numbness in right buttock and lower leg. He stated that the pain was worse in the morning with a sharp, burning sensation that radiates from his hip down to his foot. The attending physician stated that, given the Veteran’s employment as a welder, there was concern for disc herniation and nerve compression due to workplace heavy-lifting. An MRI of the Veteran’s lumbar spine from February 2016 revealed degenerative disc disease and mild facet arthropathy at the L4-L5 joint. There was also mild to moderate right and mild left foraminal narrowing. The first element of the Hickson test, the existence of a current disability, has been satisfied by the Veteran’s complaints of persistent right leg pain. The Veteran is competent to provide evidence regarding matters that can be perceived by the senses. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Although the Veteran is not competent to diagnose himself with radiculopathy, he is competent to report leg pain. Under Clemons, the Board is directed to consider complaints affecting various parts of the body rather than particular diagnoses. As such, the Board finds the Veteran’s complaints to be indicative of an underlying disorder, which continues to be ongoing. The second prong of the Hickson analysis, an in-service event or injury, has been met by medical evidence of a right hamstring injury that occurred prior to separation, as documented in the Veteran’s service treatment records. The third element of the Hickson test, that being a nexus between the current disability and the in-service disease or injury, has been satisfied by the opinion of the December 2015 VA examiner. After reviewing the claims file, the examiner found that the Veteran’s right leg condition is not radiculopathy, but residuals of the right hamstring injury he sustained during service. Given that this is the only medical opinion on record to directly address the nature of the Veteran’s right leg condition, the Board hereby adopts this characterization. The Board finds the opinion of the December 2015 VA examiner to be highly probative, given that his conclusions are based on a review of the claims file as well as his own medical expertise. The only evidence to the contrary is the statement of the attending physician from January 2016 and the accompanying MRI, which suggest the possibility of nerve compression due to the physical stresses of post-service employment. However, the Board does not find this evidence convincing given the Veteran’s complaints of right leg pain long pre-dating this assessment as well as the continuing absence of any objective evidence of radiculopathy. The preponderance of the evidence therefore supports the existence of a right leg condition that manifested during service, which is characterized as residuals of a right hamstring injury. As such, the Board finds that the Veteran’s right leg condition satisfies the requirements of the 3-part test set forth in Hickson. Accordingly, he is entitled to service connection for a right leg condition. JONATHAN B. KRAMER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD MJS, Associate Counsel