Citation Nr: 18148528 Decision Date: 11/08/18 Archive Date: 11/07/18 DOCKET NO. 14-28 207A DATE: November 8, 2018 ORDER Service connection for bilateral varicose veins and a bilateral foot disorder, including as secondary to service-connected coronary artery disease (CAD), is denied. REMANDED Entitlement to service connection for a gastrointestinal disorder is remanded. FINDING OF FACT The preponderance of the competent medical evidence is against a finding that the Veteran’s bilateral varicose veins and bilateral foot disorder are associated with his service, nor are they proximately due to or the result of his service-connected CAD or aggravated by his service-connected CAD. CONCLUSION OF LAW The criteria for service connection for bilateral varicose veins and a bilateral foot disorder, including as secondary to service-connected CAD, have not been met. 38 U.S.C. § 1110 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.310 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from September 1969 to April 1971. He served honorably in the United States Army, including in Vietnam, and he earned the Combat Infantryman Badge. The Board thanks the Veteran for his service to our country. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a June 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. This matter was previously before the Board in September 2016 when new and material evidence was granted as to the claims herein and they were remanded for further development on the merits, to include so that the Veteran could be afforded VA examinations to assess the nature and etiology of his disabilities. At that time, this appeal also included claims for service connection for neuropathy of the bilateral upper and lower extremities; however, following the Board remand, in March 2017 the RO granted all of the neuropathy claims. Accordingly, as there remains no case or controversy for the Board to resolve regarding the neuropathy claims, they are not for consideration here. Entitlement to service connection for bilateral varicose veins and a bilateral foot disorder Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Secondary service connection requires: (1) a service connected disability; (2) a nonservice connected disability; and (3) evidence that the nonservice connected disability is either (a) proximately due to or the result of the service-connected disability or (b) aggravated (increased in severity) by the service-connected disability. See 38 C.F.R. § 3.310. For the purpose of evaluating lay evidence, to include a veteran’s statements about his health conditions, competent evidence is “limited to that which the witness has actually observed, and is within the realm of his personal knowledge.” Layno v. Brown, 6 Vet. App. 465, 469-470 (1994). For example, although a lay person is competent to report observable symptoms of an injury or illness (such as pain or the visible flatness of the feet), a lay person is “not competent to opine as to medical etiology or render medical opinions.” Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). Here, pursuant to February 2017 VA examination reports, the Veteran has current diagnoses of bilateral varicose veins and bilateral foot disorders, namely, hammer toes and hallux valgus. In his August 2011 filing to reopen these claims, he contended that his conditions are secondary to his service-connected CAD, which is presumptively service-connected on the basis of conceded Agent Orange exposure during his confirmed service in Vietnam. Previously, his claims have also been considered in terms of direct service connection. However, turning to the question of whether there is a nexus, or link, between the Veteran’s current disabilities and his service, as well as whether they are proximately due to or the result his service-connected CAD or aggravated by it, the Board concludes that the preponderance of the competent medical evidence is against such a finding. The February 2017 VA examiner opined that the Veteran’s bilateral varicose veins are less likely than not incurred in or caused by his service. The examiner’s opinion was supported by rationale, to include that the April 1971 separation medical examiner affirmatively indicated that his vascular system and lower extremities were normal, lay statements from the Veteran that his varicose veins became prominent in the 1980s, and consideration of the Veteran’s service history and subsequent treatment. Regarding secondary service connection due to CAD which has been service-connected on the basis of Agent Orange exposure, it was also opined that it is less likely than not that the Veteran’s bilateral varicose veins were caused or aggravated by service-connected CAD. The examiner’s opinion was supported by rationale, to include that medical literature does not show an etiological or pathophysiological link between the two conditions and an analysis of the risk factors for developing varicose veins. Accordingly, based on a preponderance of the competent medical evidence, service connection for bilateral varicose veins is not warranted. As to the Veteran’s bilateral foot disorder, the Board notes that his neuropathy symptoms are already service-connected; the question now is whether his current diagnoses of hammer toes and hallux valgus also warrant service connection. On that point, the February 2017 VA examiner opined that the Veteran’s bilateral foot disorders are less likely than not incurred in or caused by his service. The examiner’s opinion was supported by rationale, to include that the April 1971 separation medical examiner affirmatively indicated that his feet were normal, consideration of the Veteran’s lay statements, and his service history and subsequent treatment. Regarding secondary service connection due to CAD, it was opined that it is less likely than not that the Veteran’s hammer toes and hallux valgus were caused or aggravated by service-connected CAD. The examiner’s opinion was supported by rationale, to include that medical literature does not show an etiological or pathophysiological link between coronary artery disease and hammer toes/hallux valgus and an analysis of the origins of the hallux valgus deformity in particular. Accordingly, based on a preponderance of the competent medical evidence, service connection for a bilateral foot disorder is not warranted. REASONS FOR REMAND Entitlement to service connection for a gastrointestinal disorder is remanded. Here, the Board concludes that a remand is warranted in order for VA to satisfy its duty to assist. In the Veteran’s March 2009 claim for service connection, he indicated that he underwent GI series testing in 1972, the year after he was discharged from the Army, at South Fulton Hospital in College Park. The Board notes that the Veteran’s service treatment records show he was diagnosed with and treated for gastroenteritis on the day of his discharge notwithstanding a normal separation medical examination that same day and he contends that he has had a gastrointestinal problem since service. Although the Veteran could not recall the name of the clinician who performed the testing at South Fulton Hospital, the Board finds that he has sufficiently identified the medical facility and date of the records in question such that an attempt to obtain them from the medical facility can reasonably be made if the necessary authorization is provided. In February 2017, the VA physician opining about a nexus for service connection indicated that even though the Veteran stated that in 1972 “the doctors could not find any apparent problem,” as he did in his March 2009 claim, “it would be beneficial to obtain the records of GI studies” from 1972. Accordingly, a remand is warranted so that VA may attempt to obtain the records in question with the assistance of the Veteran in providing the necessary authorizations. The matter is REMANDED for the following action: 1. Please associate with the claims file all outstanding VA and non-VA medical records pertaining to the Veteran’s gastrointestinal disorders, to include: (a.) Treatment records from South Fulton Hospital in College Park, Georgia, or its successor facility, from 1972 after obtaining any necessary authorization along with any further identifying information from the Veteran. 2. After the record is determined to be complete, please obtain an addendum medical opinion from the clinician who authored the February 2017 nexus opinion. [If that clinician is unavailable, another qualified medical professional may provide the requested opinion. If another examination is needed for the opinion sought, it should be arranged.] The claims file should be made available to and reviewed by the clinician. The opinion must address the following: (a.) Is it at least as likely as not (i.e., at least a 50 percent probability) that the Veteran has a current gastrointestinal condition, to include GERD, gastritis, or gastroenteritis, related to his service? In rendering this opinion, any records of the Veteran’s treatment at the South Fulton Hospital in College Park, or its successor facility, from 1972 should be considered and discussed as necessary. The clinician should consider and discuss the relevant evidence as necessary. A complete explanation should be provided for all opinions given. If an opinion cannot be provided without resorting to speculation, such should be stated and an explanation as to why this is so given with a note as to what, if any, additional evidence would permit such an opinion to be made. M. C. GRAHAM Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. Fales, Associate Counsel