Citation Nr: 18158501
Decision Date: 12/18/18	Archive Date: 12/17/18

DOCKET NO. 17-40 718
DATE:	December 18, 2018
ORDER
Entitlement to service connection for a left foot disorder, for accrued benefits purposes, is denied.
Entitlement to service connection for a right foot disorder, for accrued benefits purposes, is denied.
Entitlement to service connection for sleep apnea, for accrued benefits purposes, is denied.
Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), for accrued benefits purposes, is denied.
Entitlement to a rating in excess of 40 percent thereafter for lumbar degenerative disc disease (DDD) with spondylolysis and spinal stenosis, for accrued benefits purposes, is denied.
Entitlement to an initial rating of 20 percent for left lower extremity radiculopathy, for accrued benefits purposes, is granted.
Entitlement to an initial rating of 20 percent for right lower extremity radiculopathy, for accrued benefits purposes, is granted.
Entitlement to a rating in excess of 10 percent for hypertension, for accrued benefits purposes, is denied.
Entitlement to an initial compensable rating for a postoperative (PO) lumbosacral scar, for accrued benefits purposes, is denied.
FINDINGS OF FACT
1.  A disorder of the left and right foot, including gout and gouty arthritis, is first shown years after active service and is unrelated to active service.  
2.  Sleep apnea is first shown years after active service and is unrelated to active service.  
3.  An acquired psychiatric disability to include PTSD is not demonstrated by the most probative evidence of record.  
4.  The Veteran’s lumbar spine disability is not manifested by unfavorable ankylosis of the thoracolumbar spine or the entire spine.  
5.  The Veteran’s left lower extremity radiculopathy is characterized by diminished sensation, and slight evidence of motor neuropathy but reflexes were normal and there were no organic changes, or decreased strength due to sciatic neuropathy.  
6.  The Veteran’s right lower extremity radiculopathy is characterized by diminished sensation and right foot drop, but reflexes were normal and there were no organic changes, and no other evidence of decreased strength due to sciatic neuropathy.  
7.  The Veteran’s hypertension has not been manifested by diastolic blood pressure readings of predominantly 110 or more; or systolic blood pressure readings of predominantly 200 or more.  
8.  The Veteran’s post-operative lumbosacral scar is asymptomatic, is not on an exposed area, is not depressed, adherent or associated with underlying soft tissue, tender, painful, unstable or otherwise symptomatic and did not impair function of the Veteran’s low back or have any disabling effect.   
CONCLUSIONS OF LAW
1. The criteria for service connection for a left foot disorder, for accrued benefits purposes, have not been met.  38 U.S.C. §§ 1110, 1112, 1131, 5107(b), 5101, 5121 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2018).
2. The criteria for service connection for a right foot disorder, for accrued benefits purposes, have not been met.  38 U.S.C. §§ 1110, 1112, 1131, 5107(b), 5101, 5121 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2018).
3. The criteria for service connection for sleep apnea, for accrued benefits purposes, have not been met.  38 U.S.C. §§ 1110, 1112, 1131, 5107(b), 5101, 5121 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310, 3.1000(c) (2018).
4. The criteria for service connection for an acquired psychiatric disorder, to include PTSD, for accrued benefits purposes, have not been met.  38 U.S.C. §§ 1110, 1112, 1131, 5107(b), 5101, 5121 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310, 3.1000(c) (2018).
5. The criteria for a rating in excess of 40 percent for lumbar DDD with spondylolysis and spinal stenosis, for the accrued benefits purposes, have not been met.  38 U.S.C. §§ 1155, 5107(b), 5121 (2012); 38 C.F.R. §§ 3.1000(c), 4.1, 4.2, 4.3, 4.7, 4.21, 4.40, 4.45, 4.49, 3.1000(c) Diagnostic Code 5243 (2018).  
6. The criteria for an initial rating of 20 percent for left lower extremity radiculopathy, for accrued benefits purposes, have been met.  38 U.S.C. §§ 1155, 5107(b), 5121 (2012); 38 C.F.R. §§ 3.1000(c), 4.1, 4.2, 4.3, 4.7, 4.14, 4.21, Diagnostic Code 8520 (2018).  
7. The criteria for an initial rating of 20 percent for right lower extremity radiculopathy, for accrued benefits purposes, have been met.  38 U.S.C. §§ 1155, 5107(b), 5121 (2012); 38 C.F.R. §§ 3.1000(c), 4.1, 4.2, 4.3, 4.7, 4.14, 4.21, Diagnostic Code 8520 (2018).  
8. The criteria for a rating in excess of 10 percent for hypertension, for accrued benefits purposes, have not been met.  38 U.S.C. §§ 1155, 5107(b), 5121 (2012); 38 C.F.R. §§ 3.1000(c), 4.1, 4.2, 4.3, 4.7, 4.14, 4.21, 4.104, Diagnostic Code 7101 (2018).
9. The criteria for an initial compensable rating for a post-operative lumbosacral scar, for accrued benefits purposes, have not been met.  38 U.S.C. §§ 1155, 5107(b), 5121 (2012); 38 C.F.R. §§ 3.1000(c), 4.1, 4.2, 4.3, 4.7, 4.14, 4.21, Diagnostic Code 7805 (2018).
REASONS AND BASES FOR FINDINGS AND CONCLUSIONS
The Veteran served on active duty in the United States Air Force from May 1955 to April 1970.  The information of record reflects that the Veteran died in January 2016.  See VA Form 27-0820a, Report of First Notice of Death; Certificate of Death.  The Veteran’s son, who is an eligible accrued benefits beneficiary, has been substituted as the Appellant for purposes of this appeal.  38 U.S.C. § 5121A; September 2016 VA Decision Letter (granting the Appellant’s request to be a substituted party for the purpose of reimbursement for the last expenses paid).   
  
This appeal to the Board of Veterans’ Appeals (Board) arose from a May 2015 decision of a Department of Veterans Affairs (VA) Regional Office (RO), which denied service connection for a left and foot disorder, sleep apnea, and an acquired psychiatric disorder, to include PTSD.  In that decision, the RO granted service connection for radiculopathy of the left and left lower extremities, with each extremity rated 10 percent, and granted service connection for a post-operative lumbosacral scar, rated noncompensable, each effective from October 13, 2014.  The RO increased the rating for ASHD with first degree heart block from 30 percent to 60 percent, effective from April 13, 2015, and increased the rating for lumbar spondylolysis from noncompensable to 20 percent, effective October 13, 2014.  The 10 percent rating for hypertension was confirmed and continued.  

In a June 2017, rating decision, the RO increased the rating for ASHD with first degree heart block from 60 percent to 100 percent, effective from April 13, 2015, for accrued benefits purposes.  The RO reclassified the service-connected lumbar spine disability (as degenerative disc disease, spondylosis, and spinal stenosis of the lumbar spine), and increased the rating for the lumbar spine disability to 40 percent, effective from October 13, 2014, for accrued benefits purposes.  The RO granted special monthly compensation (SMC) based on housebound (HB) criteria, effective from April 13, 2015, for accrued benefits purposes; and granted basic eligibility to Dependents’ Educational Assistance (DEA) benefits, effective from April 13, 2015, for accrued benefits purposes.  

In a July 2017 letter, which was accepted as a Substantive Appeal, the Appellant, by and through his attorney, maintained that the proper effective date for a TDIU rating would have been the date of the Veteran’s underlying claim for an increased rating, which was received on October 13, 2014.  In an October 2017 rating decision, the RO granted an effective date of October 13, 2014 for: (1) the assignment of a 100 percent schedular rating for ASHD with first degree heart block, (2) SMC based on HB criteria, and (3) basic eligibility for DEA benefits, each for accrued benefits purposes.  As such, the matter of a TDIU was considered moot.  

This appeal has been advanced on the Board’s docket pursuant to 38 C.F.R. § 20.900(c) (2017).  38 U.S.C. § 7107(a)(2) (West 2014).
Background

The service treatment records (STRs) reveal that a June 1954 examination in conjunction with Air Force ROTC training revealed no pertinent abnormality.  

An examination in May 1955 for pilot training in grade, revealed no pertinent abnormality.  

An annual examination in 1961, examination for service overseas in December 1963, and a periodic examination in February 1965 revealed no pertinent abnormality.  In adjunct medical history questionnaires at those times the Veteran denied having or having had bone, joint, or other deformity; lameness; foot trouble; frequent trouble sleeping; frequent or terrifying nightmares; depression or excessive worrying; loss of memory or amnesia; nervous trouble of any sort; or excessive drinking habit.  

In January and in February 1964 the Veteran had a viral upper respiratory infection (URI).  

A periodic examination in March 1968 revealed no pertinent abnormality. 

A March 1970 electroencephalogram, conducted due to the Veteran’s headaches, revealed occasionally suspicious looking sharp waves during hyperventilation but normal sleep patterns were noted.  

In October 1969 the Veteran had a history of recurrent strep throat.  The diagnoses were a URI and bronchitis.  

A February 1970 neurology evaluation found that the Veteran had vascular headaches and hypertension, and that he was fit for separation from service.  

On examination for service separation in February 1970 it was reported that the Veteran had headaches and back pain but the physical examination revealed no pertinent abnormality.  In an adjunct medical history questionnaire the Veteran reported, in pertinent part, having or having had headaches, cramps in his legs, and recurrent back pain.  He denied having or having had bone, joint, or other deformity; lameness; foot trouble; frequent trouble sleeping; frequent or terrifying nightmares; depression or excessive worrying; loss of memory or amnesia; nervous trouble of any sort; or excessive drinking habit.  

In conjunction with examinations during the Veteran’s service in the Air Force Reserves he reported in a medical history questionnaire in December 1973 not having or having had bone, joint, or other deformity; lameness; foot trouble; frequent trouble sleeping; frequent or terrifying nightmares; depression or excessive worrying; loss of memory or amnesia; nervous trouble of any sort.  

An examination in June 1976, in the Air Force Reserves, was negative and at that time he weighed 153 lbs.  In an adjunct medical history questionnaire, he reported having or having had frequent trouble sleeping as well as depression or excessive worrying but he denied having or having had lameness; foot trouble; loss of memory or amnesia; nervous trouble of any sort.  His present medications included Valium.  

In conjunction with examinations during the Veteran’s service in the Air Force Reserves he reported in medical history questionnaires in October 1978 not having or having had bone, joint, or other deformity; lameness; foot trouble; frequent trouble sleeping; frequent or terrifying nightmares; depression or excessive worrying; loss of memory or amnesia; nervous trouble of any sort.

On VA general medical examination in July 1970 it was reported that the Veteran had a history of headaches which began in 1960 and occurred about once monthly.  He took Fiorinal for relief of nausea and vomiting.  He had had severe low back pain since 1957 but was not taking any medication.  On physical examination had had a normal sinus rhythm of his heart, no murmurs and no cardiomegaly.  There was no peripheral arteriosclerosis and no abnormal pulsations.  He had no hernia.  His gait was normal.  He had full motion and strength of his back and extremities.  He reported having tenderness of pressure of the right side of the sacrum.  There was no atrophy or spasm of his back.  Straight leg raising was negative.  There was no abnormality of sensation or the muscles of his lower extremities.  There was no calf or quadriceps atrophy.  He did not have weak feet.  The relevant diagnoses were hypertension; obesity; and impaired function of the back not found.  X-rays revealed straightening of the normal lordotic curvature consistent with muscle spasm.  The vertebral elements and interspaces were otherwise normal.  

On VA neuropsychiatric examination in July 1970 the Veteran’s chief complaint was headaches which began around both eyes, in the orbital sections, and remained there but grew in intensity to the point of causing nausea.  He was treated at an Air Force Base and took Fiorinal tablets which sometimes gave relief.  He sometimes awoke with these headaches which caused nausea but after eating in the morning he was able to go to work.  He described his married life as being satisfactory and reported having an adequate social life.  He and his wife did not go out much but when they did they enjoyed themselves.  One of the reasons they did not go out much was because his wife had a long-time aliment of the back.  He was fully oriented and did not exhibit psychiatric material in the form of delusions, hallucinations, or ideas of reference.  He had considerable concern about his headaches because he was unaware of the cause of the headaches.  He described himself as being somewhat of a driven person, such that when he had a project to do he wanted to get at it right away and work with zeal until completion.  The examiner indicated that this was perhaps not conducive to the Veteran’s headaches and the examiner did not consider the Veteran to be a compulsive person.  It was felt that a diagnosis of migraine headaches of unknown origin would be satisfactory. 

On VA general medical examination in August 1975 it was reported that the Veteran continued to have low back pain and that his headaches continued despite taking medication.  He had been hospitalized in 1974 for removal of kidney stones.  On physical examination there was no spinal tenderness or paravertebral muscle spasm.  Straight leg raising was negative, deep tendon reflexes were equal, and there was no motor weakness.  Lumbosacral X-rays were compatible with degenerative changes.  The diagnoses were hypertension and headaches.  

A December 29, 1975 letter from Dr. P. Mitsopoulos states that the Veteran had been treated since February 1973 for hypertension.  A treadmill test was positive and revealed coronary artery disease, and angina pectoris.  On examination of December 23, 1975, he continued to have chest pain and shortness of breath (SOB) on exertion and his medications included Inderal, Isordil, Hydrodiuril, Valium, and Nitroglycerin.  The diagnoses were hypertension and arteriosclerotic heart disease (ASHD), Ischemic heart disease, and rule out a hiatal hernia and gallbladder disease.  

On VA examination in March 1976 the Veteran complained of severe low back pain, frequent headaches which when severe were accompanied by nausea, frequent high blood pressure, and extreme nervousness.  He also complained of exertional dyspnea.  On examination it was noted that he was obsessive and anxious but cooperative.  Coordination and sensations were intact.  Reflexes were all 2 and his muscle bulk, tone, and strength were intact.  It was reported that he had had reactive depression in response to recent domestic difficulties due to a divorce.  He felt depressed and lonely with sleep disturbance.  The examiner suggested that the Veteran seek counseling.  The diagnoses were mild hypertension with headaches, controlled with medications; ASHD by history with first degree heart block; no hypertension found and it was doubted that anti-hypertensive medication was needed; and a history of kidney stones.  

In April 1976 Dr. R. Matthews reported that the Veteran had been hospitalized in March 1976 for cardiac catheterization.  

Of record is VA Form 21-4138, Statement in Support of Claim, dated October 13, 2014, in which the Veteran claimed service connection for a “foot condition,” “sleep apnea,” “PTSD” and increased ratings hypertension and his spinal condition with intervertebral disc syndrome (IVDS).  

In April 2015 the Veteran was furnished a form and requested to provide details of any alleged stressor(s).  However, the Veteran never executed and returned the form.  

On VA hypertensive examination in April 2015 the Veteran reported having had treatment since 1970 for hypertension, to keep it under control.  His treatment plan included taking continuous medication for hypertension.  The medications were Furosemide, Felodipine, Fosinopril, and Imdur.  Of record is an April 13, 2015 “Vitals Sheet” which reflects that the Veteran was taking medication for hypertension.  His blood pressure in his left arm was 105/54 and on a second reading it was 110/52, and in the right arm it was, on a single reading, 110/50.  He did not have a history of diastolic blood pressure elevation to predominantly 100 or more.   The examiner reported that the Veteran’s hypertension did not impact his ability to work.  The Veteran reported that he had not participated in combat.  Fundoscopic examination of the eyes was normal.  There was edema of both lower extremity, worse on the left at 2+ and only 1+ on the right.  

On VA examination in April 2015 of the Veteran’s thoracolumbar spine the diagnoses were degenerative disc disease (DDD), intervertebral disc syndrome (IVDS), spondylolisthesis, retrolisthesis, disc bulging, spinal stenosis and neural foraminal narrowing, and spondylosis of the lumbar spine.  The Veteran reported having flare-ups which impacted low back function and stated that he had had low back pain that began during service and had progressively worsened.  The examiner also noted, in part, that the Veteran was claiming sleep apnea, a foot disorder, arthritis, and nightmares.  The Veteran reported having had back surgery in 1989 and that a 2012 MRI had revealed continuing problems at L4 and L5 and a 2014 MRI had revealed severe spinal stenosis.  However, because of his age and other health problems, physicians had recommended that that he not have further low back surgery.  

On physical examination the Veteran had thoracolumbar flexion to 65 degrees, with pain beginning at 60 degrees.  Extension was to 15 degrees, with pain beginning at 10 degrees.  Right lateral bending was to 10 degrees, with pain beginning at 5 degrees.  Left lateral bending was to 5 degrees, with pain beginning at that point.  Right lateral rotation was to 15 degrees, with pain beginning at 5 degrees.  Left lateral rotation was to 5 degrees with pain beginning at that point.  These ranges of motion remained unchanged after three (3) repetitions of motion, i.e., there was no additional loss of motion after repetition of motion testing.  The examiner reported that the Veteran had functional loss or impairment due to less movement than normal, weakened movement, excess fatigability, painful motion, disturbance of locomotion, and interference with sitting, standing and /or weight-bearing.  His posture was within normal limits.  

Also on examination the Veteran did not have localized tenderness or pain to palpation, and there was no guarding or muscle spasm.  Strength was normal, bilaterally, in hip flexion, knee extension, ankle plantar flexion, ankle dorsiflexion, and great toe extension.  There was no muscle atrophy.  Deep tendon reflexes were all normal.  Sensations were normal in the upper anterior thighs (L2), but decreased at the thighs and knees (L3/4), lower legs and ankles ((L4/L5/S1), and feet and toes (L5).  Straight leg raising was positive, bilaterally.  He had radicular pain in the lower extremities which was constant and moderate; but also had intermittent pain which was moderate in the right lower extremity and severe in the left lower extremity.  He had paresthesias and/or dysesthesias which was moderate in the right lower extremity and severe in the left lower extremity.  He had numbness which was moderate in each lower extremity.  The involvement was the sciatic nerve in each lower extremity which was moderate in the right leg and severe in the left leg.  There were no other neurologic abnormalities and, while he had IVDS, he had not had any incapacitating episodes in the past 12 months.  He constantly used a walker as an ambulatory aid due to back pain.  

The Veteran had a postoperative thoracolumbar scar which was not painful or unstable.  The scar was 7 cms. by 0.3 cms.  The examiner reviewed a June 2014 lumbar MRI and it revealed disc bulging, osteophytes, spondylolisthesis, retrolisthesis, foraminal narrowing, and severe spinal stenosis.  The examiner reported that the disability impacted the Veteran’s ability to work in that he had difficulty walking, standing, and ambulating with a walker.  

The examiner further stated that there were contributing factors of pain, weakness, fatigability and/or incoordination and there was additional limitation of functional ability of the thoracolumbar spine during flare-ups or repeated use over time.  The degree of range of motion loss during pain on use or flare-ups was approximately lumbar forward flexion of 30 degrees.  The Veteran also had swelling of his legs.  

On VA cardiovascular examination in May 2015 the Veteran’s blood pressure readings were 118/60, 120/58, and 118/58.  There was no peripheral edema of the lower extremities.  

A May 11, 2015, Formal Finding On a Lack of Information Required to Verify Stressors In Connection With PSTD Claim reflects that the RO determined that the information required to concede PTSD was insufficient to send to “CURR” and/or insufficient to research the case for an Air Force record.  All procedures to obtain this information from the Veteran have been properly followed.  Evidence of written and telephonic efforts to obtain this information was in the file.  All efforts to obtain the needed information had been exhausted, and any further attempts would be futile.  The efforts made to obtain the information necessary to verify stressful events for the PTSD claim were sending VA Form 21-0781 and 21-0781a to the Veteran in correspondence dated April 2, 2015; however, no response was received from the Veteran.  Service treatment records and postservice treatment records are negative for PTSD diagnosis or symptoms.  

On VA examination of December 17, 2015 for evaluation of the Veteran’s service-connected headaches it was noted that the Veteran reported that he had no participated in combat.  

On VA examination of December 17, 2015 for evaluation of the Veteran’s service-connected hemorrhoids, it was found that his hemorrhoids were in remission.  It was noted that the Veteran reported that he had no participated in combat.  

Voluminous private clinical records were received in November 2015 reflecting treatment after active service by Dr. Charles Azzam, Dr. Khroso Shareghi, and Dr. Siamak Heydarian.  

Received in November 2015, was a report of a June 10, 2014, lumbar MRI by Sentara Healthcare which reflects that the Veteran had mild diffuse disc bulging at T12-L1 with a small annulus tear and thecal sac impingement, without significant change since December 3, 2012; mild disc osteophyte complex at L3-L4 with mild thecal sac impingement, and stable left foraminal/lateral L3-L4 disc protrusion; Grade 1 L4-L5 spondylolisthesis with disc osteophyte complex and facet and ligamentum flavum hypertrophy impinging on the thecal sac and creating severe spinal stenosis which had mildly worsened since December 3, 2012, with mild scar tissue within the right anterior spinal canal and lateral recess at L4-L5; Grade 1 L5-S1 retrolisthesis with disc osteophyte complex impinging on the thecal sac and moderate to marked right lateral disc protrusion mildly worsening from before, and mild scar tissue within the right anterior portion of the spinal canal related to the right S1 nerve root; and L3-L4 through L5-S1 neural foraminal narrowing, most severe at L4-L5 and L5-S1 without significant change.  

Dr. Charles Azzam

Received in November 2015 were treatment records of Dr. Charles Azzam.  Records of a June 5, 2014, office visit to Dr. C. Azzam shows that the Veteran complained of moderate weakness from his waist to his ankles of five years duration.  The Veteran reported that his symptoms began after he developed blood clots in his legs five years ago.  He had had a right L4-5 discectomy in 1985 with residual right foot dorsiflexion weakness.  He related that his symptoms were interfering with his activities, e.g., he had difficulty getting out of a chair.  He had no bowel or bladder sphincter dysfunction.  He had no pain in his neck, low back, or legs.  He had spent over 2 weeks at a health and therapy center, and had had 10 physical therapy sessions.  The Veteran complained of difficulty walking.  He had no memory loss but complained of anxiety.  His blood pressure was 183/73.  He had normal alignment and mobility of his head and neck but moderately decreased range of motion of the trunk.  He had normal range of motion and strength in all upper and lower extremities.  Reflexes were 2+ and symmetric with no pathologic reflexes.  Sensory status was intact to touch.  There was no weakness.  His judgment was intact and he was fully oriented.  Although he extended slowly, lumbar flexion was to 45 degrees (and the range of motion in other planes was not reported).  There was no paraspinal muscle tenderness.  The diagnosis was lumbosacral spondylosis without myelopathy.  He presented with a feeling of bilateral lower extremity weakness, possibly on the basis of evolving lumbar/thoracic canal stenosis, but there was no evidence of significant myelopathy.  

Records of Dr. Azzam include a June 18, 2014 electromyography and nerve conduction study which was significantly abnormal and suggestive of left L5 nerve root involvement, right L5 radiculopathy, and right S1 nerve root involvement.  There was evidence of peripheral sensory/motor neuropathy but no electromyographic evidence of myopathy.  

Records of a July 10, 2014, office visit to Dr. C. Azzam for a neurosurgical spinal evaluation show that the Veteran complained of moderate weakness from his waist to his ankles of five years duration.  His overall condition was materially unchanged from prior evaluation on June 5, 2014.  There was no bowel or bladder sphincter dysfunction.  He denied having back and leg pains.  A June 10, 2014 lumbar MRI had revealed significant lumbar canal stenosis extending from L3 to L5 and most severe at the L4-L5 level.  There was grade 1 retrolisthesis of the L5-81 level.  There was significant neural foraminal narrowing, bilaterally, from L3 to S1 and most severe at the L4-L5 and L5-81 level.  The degree of lumbar spinal stenosis had worsened since December 3, 2012.  There was a 7-mm. synovial cyst at the left L4-L5 facet joint.  There are postoperative changes at the right L4-L5 and L5-S1 levels. There was no evidence of spondylolisthesis at the L4-L5 level.  The Veteran stated that his condition had improved since his last visit and he did not wish any surgical intervention.  On physical examination his blood pressure was 137/73.  His station and gait were normal.  He had normal range of motion and strength in all upper and lower extremities.  Reflexes were 2+ and symmetric with no pathologic reflexes.  Sensory status was intact to touch.  There was no weakness.  His judgment was intact and he was fully oriented.  Although he extended slowly, lumbar flexion was to 45 degrees (and the range of motion in other planes was not reported).  There was no paraspinal muscle tenderness.  The physician concluded that the Veteran had symptoms related to a progressive severe lumbar canal stenosis maximally at the I 4-L5 level.  It was recommended that he continue his back muscle and leg strengthening exercises and to refrain from strenuous activities.  

Dr. Khosro Shareghi

Received in November 2015 were treatment records of Dr. Khosro Shareghi.  In a May 22, 1992, letter Dr. K. Shareghi reported that the Veteran had long-standing hypertension and had had the recent onset of swelling of his legs which was treated with diuretics, which helped the swelling but only temporarily.  Also, he had a history of gout and arthritis.  His blood pressure was 142/96.  

Records of Dr. Khosro Shareghi include a report of an April 20, 2011 cardiac perfusion study noted that the Veteran’s blood pressure had been 144/75 prior to the study and 142/74 during the test.  A report of an April 27, 2012, cardiac perfusion study noted that the Veteran’s blood pressure had been 150/67 prior to the test and increased to 164/78 during the test. 

Records of Dr. Shareghi show that the Veteran underwent repeated cardiovascular evaluations from 2011 through 2015.  On January 11, 2011, his blood pressure was 140/70.  On April 18, 2011, his blood pressure was 140/70.  On July 11, 2011, it was 110/60.  On July 21, 2011, it was 116/60.  On October 21, 2011, it was 100/60.  On January 24, 2012, it was 134/62.  On April 12, 2012, it was 122/64.  At the time that all of these blood pressure readings were taken neurological and psychiatric evaluations were negative.  

A May 8, 2012, abdominal ultrasound revealed mild atherosclerotic changes in the distal abdominal aorta and a doppler study of both lower extremities revealed mild peripheral arterial disease.  On August 1, 2012, his blood pressure was 100/60.  On November 5, 2012, it was 132/70.  On December 12, 2012, it was 122/68.  On March 11, 2013, it was 130/70.  On April 11, 2013, it was 122/72.  At the time all of these blood pressure readings were taken neurological and psychiatric evaluations were negative.  

On July 18, 2013, on a cardiac work-up the Veteran complained of dyspnea and angina on exertion and general weakness.  Neurological and psychiatric evaluations were negative.  His blood pressure was 92/50.  The impressions included low blood pressure.  On July 25, 2013, his blood pressure was 110/50 and on August 15, 2013, it was 100/60; and on both occasions neurological and psychiatric evaluations were negative.  

On September 10, 2013, his blood pressure was 122/60.  He was normotensive.  A doppler study of both lower extremities revealed mild peripheral arterial disease.  On September 30, 2013, his blood pressure was 110/60.  He was normotensive.  On October 14, 2013, his blood pressure was 110/60.  He was normotensive.  On October 28, 2013, his blood pressure was 98/58.  He was noted to be mildly hypotensive.  On November 4, 2013, his blood pressure was 132/70.  He was normotensive.  On November 14, 2013, his blood pressure was 126/68.  On December 13, 2013, his blood pressure was 128/60.  On January 14, 2014, it was 110/60.  On March 12, 2014, it was 170/80.  On April 18, 2014, it was 132/60.  On August 15, 2014, it was 140/72.  On November 12, 2014, it was 130/70.  

On February 11, 2015, the Veteran’s blood pressure was 126/74.  On May 12, 2015, it was 128/68.  On August 13, 2015, it was 122/68, and another progress note of that same date reflects that his blood pressure was 126/64.  On September 17, 2015, it was 92/48.  On September 24, 2015, it was 152/70.  On October 26, 2015, it was 120/62.  On November 24, 2015, it was 158/72.  On all of these occasions neurological and psychiatric evaluations were negative.  

Included with the records from Dr. S. Heydarian is an April 22, 2014, report from Prince William Neurology which noted that the Veteran was evaluated for low back pain syndrome and lumbar spondylosis as well as “sleep disorder/abductors sleep apnea dizziness nightmares and hyposmia.”  He took medication for bladder control and his bowel control was not as good as it used to be, and he complained of constipation.  He felt nervous at times.  His nightmares were “better than before.”  He used a CPAP device at home for obstructive sleep apnea (OSA).  On sensory examination there was decreased vibratory sense in the great toes.  On motor examination he had difficulty arising from a seated position.  He had weakness of the right foot, which was “old.”  Lumbar flexion was reported to be to 80 degrees, and was also reported to be to 90 degrees.  Straight leg raising was negative, bilaterally.  Deep tendon reflexes were normal without any Babinski’s signs.  The assessments included lumbar spondylosis and obstructive sleep apnea (OSA).  
Dr. Siamak Heydarian

Received in November 2015 were treatment records of Dr. Siamak Heydarian since 1992, and include numerous clinical records from other sources.  

A July 31, 1992, statement by Dr. K. Shareghi shows that the Veteran had swelling of the lower extremities due to venous insufficiency, as shown by noninvasive studies of the lower extremities which revealed incompetent valves in both lower extremities.  
A February 21, 2001, record of Dr. Heydarian shows that the Veteran’s blood pressure was 138/84.  He Veteran had had an injury with contusion of the left great toe and had a weak left dorsalis pedis pulse, and the assessments included peripheral vascular disease (PVD) of the lower extremities, by doppler study.  X-rays of February 22, 2001, of the Veteran’s “right” great toe revealed a healing non-displaced fracture of the distal portion of the proximal phalanx and fairly prominent degenerative changes at the metatarsophalangeal joint.  

A March 1, 2001, bilateral ultrasound at the Potomac Hospital, done due to leg swelling was negative.  An April 13, 2001, progress note from Cardiac Care Centers shows that neurologic and psychiatric evaluations were negative, and his blood pressure was 138/76.  A May 16, 2001, record of Dr. Heydarian shows that his blood pressure was 122/78.  A May 16, 2001, progress note from Cardiac Care Centers shows that neurologic and psychiatric evaluations were negative, and his blood pressure was 150/80.  A June 8, 2001, progress note from Cardiac Care Centers shows that neurologic and psychiatric evaluations were negative, he had prostatic hypertrophy, and his blood pressure was 130/90.  A June 13, 2001, record of Dr. Heydarian shows that blood pressure was 140/86.  A July 6, 2001, progress note from Cardiac Care Centers shows that neurologic and psychiatric evaluations were negative, and his blood pressure was 140/72.  An August 8, 2001, record of Dr. Heydarian shows that his blood pressure 140/78.  An October 17, 2001, record of Dr. K. Shareghi shows that neurologic and psychiatric evaluations were negative, and his blood pressure was 140/80.   Contained in the records of Dr. Heydarian is a list of 11 blood pressure readings, apparently self-taken by the Veteran, from October 20, 2001 to November 29, 2001 which shows systolic readings ranging from 134 to 163 and diastolic readings ranging from 67 to 82.  

A November 6, 2001, record of Dr. Heydarian shows that the Veteran’s blood pressure was 176/80.  A January 7, 2002, record shows that it was 135/76.  A March 14, 2002, shows that it was 120/70.  A March 19, 2002, record shows it was 116/65.  A June 11, 2002, shows it was 109/57.  A June 21, 2002, record shows it was 120/70 and that neurologic and psychiatric evaluations were negative.  

A June 14, 2002, record of Dr. Nejad shows that the Veteran’s blood pressure was 133/74.  An August 30, 2002, record of Dr. Lou shows that the Veteran had urinary symptoms of an enlarged prostate.   A September 11, 2002, record of Dr. Heydarian shows that the Veteran’s blood pressure was 132/69.  A September 26, 2002, record of Dr. K. Shareghi shows it was 124/82 and that neurologic and psychiatric evaluations were negative.  A December 19, 2002, record of Dr. Heydarian shows that blood pressure 112/64.  

A March 15, 2003, record of Dr. K. Shareghi shows that neurologic and psychiatric evaluations were negative, and his blood pressure was 120/74.  A March 19, 2003, record of Dr. Heydarian shows that his blood pressure was 131/71.  A June 19, 2003, record of Dr. Heydarian shows that his blood pressure was 125/65, and the Veteran had tenderness over the right lumbosacral area and slight paralumbar spasm.  

An August 19, 2003, record of Dr. K. Shareghi shows that neurologic and psychiatric evaluations were negative, and the Veteran’s blood pressure was 144/80.  An August 20, 2003, Progress note from Dr. K. Shareghi shows blood pressure was 150/74.  An August 27, 2003, Progress note from Dr. K. Shareghi shows that the Veteran’s blood pressure was well controlled, at 126/74, since his blood pressure medication was increased, and he did not have any side effects.  

A September 11, 2003, record of Dr. Heydarian shows that the Veteran’s blood pressure was 120/62.  An October 1, 2003, bilateral ultrasound at the Potomac Hospital, done due to bilateral leg edema, found no evidence of deep venous thrombosis of either leg.  A November 13, 2003, record of Dr. K. Shareghi shows that blood pressure was 126/80 and that neurologic and psychiatric evaluations were negative.  A December 3, 2003, record of Dr. Heydarian shows that blood pressure was 118/63.  A January 12, 2004, record of Dr. K. Shareghi shows that neurologic and psychiatric evaluations were negative, and blood pressure was 126/70.  A March 4, 2004, record of Dr. Heydarian shows that blood pressure was 115/60.  A May 5, 2004, record of Dr. Heydarian shows that blood pressure was 135/64.  A May 27, 2004, record of Dr. K. Shareghi shows that neurologic and psychiatric evaluations were negative, and blood pressure was 130/70.  A September 2, 2004, record of Dr. K. Shareghi shows that neurologic and psychiatric evaluations were negative, and blood pressure was 118/72.  A September 7, 2004, record of Dr. Heydarian shows his blood pressure was 120/63.  A December 3, 2004, record of Dr. K. Shareghi shows that neurologic and psychiatric evaluations were negative, and blood pressure was 120/84.  

A January 6, 2005, Progress note from Dr. K. Shareghi shows that the Veteran’s systolic blood pressure readings, taken at home, ranged from 130 to 140.  A January 11, 2005, record of Dr. Heydarian shows that blood pressure was 134/72.  An April 7, 2005, record of Dr. K. Shareghi shows that neurologic and psychiatric evaluations were negative, and blood pressure was 130/70.  An April 19, 2005, record of Dr. Heydarian shows that blood pressure was 130/65.  A June 7, 2005, record of Dr. K. Shareghi shows that neurologic and psychiatric evaluations were negative, and blood pressure was 120/70.  A July 19, 2005, record of Dr. Heydarian shows that blood pressure was 118/61.  A September 7, 2005, record of Dr. K. Shareghi shows that neurologic and psychiatric evaluations were negative, and blood pressure was 120/70.  An October 18, 2005, record of Dr. Heydarian shows that blood pressure was 117/58.  A December 7, 2005, record of Dr. K. Shareghi shows that neurologic and psychiatric evaluations were negative, and blood pressure was 110/60.  

A January 16, 2006, record of Dr. Heydarian shows that the Veteran’s blood pressure was 113/58.  A February 15, 2006, record of Dr. Heydarian shows that blood pressure was 119/70 and on February 22, 2006, blood pressure was 118/60.  A March 22, 2006, record of Dr. K. Shareghi shows that neurologic and psychiatric evaluations were negative, and blood pressure was 110/60.  An April 24, 2006, record of Dr. Heydarian shows that blood pressure was 100/49.  A June 1, 2006, record of Dr. K. Shareghi shows that neurologic and psychiatric evaluations were negative, and blood pressure was 140/72.  A June 13, 2006, record of Dr. Heydarian shows that blood pressure was 115/61.  An August 1, 2006, report from Dr. R. Hwang shows that in July 2006 the Veteran had a 3-day history of pain and swelling of the right hand, and an examination revealed cellulitis of the right hand.  He had been diagnosed as having gout 20 years ago.  After considering his uric acid level it was felt that the Veteran had gout and gouty arthritis/synovitis of the right hand.  

An August 26, 2006, record of Dr. Heydarian shows that the Veteran’s blood pressure was 123/66.  A September 27, 2006, record of Dr. K. Shareghi shows that neurologic and psychiatric evaluations were negative, and blood pressure was 160/82.  An October 30, 2006, record of Dr. K. Shareghi shows that neurologic and psychiatric evaluations were negative, and blood pressure was 137/70.  A November 27, 2006, record of Dr. Heydarian shows that blood pressure was 128/65.  

A February 26, 2007, record of Dr. Heydarian shows that the Veteran’s blood pressure was 127/62.  An April 9, 2007, record of Dr. K. Shareghi shows that neurologic and psychiatric evaluations were negative, and blood pressure was 126/76.  A June 4, 2007, record of Dr. Heydarian shows that blood pressure was 131/62, and on July 6, 2007 it was 124/60 and on July 18, 2007 it was 169/81.  A July 9, 2007, record of Dr. K. Shareghi shows that neurologic and psychiatric evaluations were negative, and his blood pressure was 120/64.  His blood pressure was well controlled with medication.  

A July 31, 2007, treatment record of Dr. Heydarian shows that the Veteran’s blood pressure was 118/58, and on September 26, 2007, it was 124/64.  An October 10, 2007, record of Dr. K. Shareghi shows that neurologic and psychiatric evaluations were negative, and blood pressure was 120/60.  On October 19, 2007, blood pressure was 177/80 and on October 29, 2007, blood pressure was 137/65.  

A November 26, 2007, record shows that the Veteran’s blood pressure was 134/69.  Another record of that date shows that the Veteran had a history of gout, affecting the left metatarsophalangeal joint.  

A January 11, 2008, record of Dr. K. Shareghi shows that neurologic and psychiatric evaluations were negative, and the Veteran’s blood pressure was 118/62.  His blood pressure was well controlled with medication.  On January 14, 2008, his blood pressure was 125/64.  On February 29, 2008, it was 153/72 and on April 16, 2008, it was 111/55.  An April 22, 2008, record of Dr. K. Shareghi shows that neurologic and psychiatric evaluations were negative, and blood pressure was 124/62.  On July 16, 2008, it was 122/56.  A July 22, 2008, record of Dr. K. Shareghi shows that neurologic and psychiatric evaluations were negative, and blood pressure was 142/68.  On September 17, 2008, blood pressure was 147/63.  

A September 17, 2008, progress note by Dr. K. Shareghi shows that neurologic and psychiatric evaluations were negative, and the Veteran’s blood pressure was 142/68 lying down and 140/60 while standing.  It was felt that his dizziness was probably due to Meniere’s disease.  A September 18, 2008, report from Prince Williams Neurology Center shows that his blood pressure was 154/80.  On examination sensory evaluation was within normal limits, bilaterally.  Motor examination was bilaterally symmetrical and normal.  Deep tendon reflexes were hypoactive without any Babinski’s sign.  Cerebellar examination was unremarkable except for mild difficulty with tandem gait.  

In October 2008 Dr. Heydarian signed the Veteran’s application for Disabled Parking Plates on the basis that he could not walk 200 feet without stopping to rest due to chronic low back pain.  

An October 15, 2008, record shows that the Veteran’s blood pressure was 109/54.  An October 21, 2008, record of Dr. K. Shareghi shows that neurologic and psychiatric evaluations were negative, and blood pressure was 110/64 lying down and 130/standing.  Electrodiagnostic tests on December 10, 2008, by Prince Williams Neurology Center shows that there was mild peripheral sensory/motor neuropathy and there was evidence of right L5 and left S1 nerve root involvement.  
On January 15, 2009, the Veteran’s blood pressure was 128/67.  A January 22, 2009, record of Dr. K. Shareghi shows that neurologic and psychiatric evaluations were negative, and blood pressure was 134/70.  

A February 16, 2009, report from NOVA Orthopedic & Spine Care shows that the Veteran had a history of right foot drop since mid-2007.  He had had difficulty dorsiflexing that foot, but he denied significant back or leg pain.  There was no significant numbness or weakness, and no bowel or bladder incontinence.  On examination he was unable to heel walk or toe walk on the right side.  He had full lumbar range of motion without pain.  Straight leg raising was negative, bilaterally.  Sensation was intact to light touch and pinprick from L1 to S1.  Knee and ankle reflexes were 1+, bilaterally.  The pertinent assessment was L4-5 right-sided foot drop.  

On April 16, 2009, the Veteran’s blood pressure was 118/60.  An April 21, 2009, Orthopedic Progress Note of Dr. G. Nejad shows that his blood pressure was 153/74.  A May 5, 2009, record of Dr. K. Shareghi shows that neurologic and psychiatric evaluations were negative, and blood pressure was 118/66.  On June 30, 2009, he had recurrent gout which was affecting the great toe of each foot.  His blood pressure was 119/60.  

An August 4, 2009, record of Dr. K. Shareghi shows that neurologic and psychiatric evaluations were negative, and blood pressure was 130/66.   A September 24, 2009, record from D. Stabile, a podiatrist, reflects that the Veteran had had an episode of gout but it did not appear to be anything other than inflammatory arthritis; X-rays had confirmed significant arthritis of the 1st metatarsophalangeal joint of the left foot.  On September 29, 2009, his blood pressure was 103/53.  A report of DNA testing of the Potomac Hospital of September 30, 2009, states that the Veteran had a genetic mutation which created an elevated risk for venous thrombosis.  

A September 30, 2009, left lower extremity ultrasound at the Potomac Hospital revealed a thrombus in the left popliteal vein extending to the posterior tibial vein and peroneal vein.  On October 8, 2009, the Veteran’s blood pressure was 139/67.  A November 13, 2009, record of Dr. K. Shareghi shows that neurologic and psychiatric evaluations were negative, and blood pressure was 132/70.  A December 9, 2009, report from Cancer & Blood Specialists of Northern Virginia shows that blood pressure was 136/67.  A December 9, 2009, doppler study from the Potomac Hospital revealed an occluding clot at the left popliteal vein to the posterior tibial vein.  On December 22, 2009, blood pressure was 104/53.  

A December 27, 2009, report of consultation from the Potomac Hospital shows that the Veteran’s blood pressure was 130/90.  He had had deep venous thrombosis since October 2009.  A December 30, 2009, report from the Potomac Hospital shows that the Veteran’s blood pressure was 126/67.  A February 22, 2010, record from Cancer & Blood Specialists of Northern Virginia shows that the Veteran’s blood pressure was 147/69.  On March 4, 2010, it was 111/59.  A March 3, 2010 record of Dr. K. Shareghi shows that neurologic and psychiatric evaluations were negative, and blood pressure was 128/68.  On March 13, 2010, blood pressure was 111/59.  An April 7, 2010 record of Dr. K. Shareghi shows that neurologic and psychiatric evaluations were negative, and blood pressure was 130/62.  A May 13, 2010, record shows that blood pressure was 111/59. 

A May 27, 2010, report from Prince William Neurology Center reflects that the Veteran had recently been treated for intestinal bleeding last Christmas when he was on Coumadin and was readmitted in February 2010.  He had had deep venous thrombosis (DVT) in the past, with 3 ultrasound studies having been positive for DVT but his leg symptoms were now better than before but his gait disorder remained essentially unchanged, and he had been falling from time-to-time.  He complained of vivid dreams every night, with nightmares and at times he awoke feeling as if the whole world was coming to an end.  He had a history of excessive snoring and awaking gasping for air.  It was recommended that he have a polysomnogram. 

A June 7, 2010, record from Dr. M. Kandahari shows that the Veteran’s blood pressure was 130/69.  A June 10, 2010, record shows his blood pressure was 110/55.  On July 10, 2010, it was 110/55.  A July 15, 2010, record of Dr. K. Shareghi shows that neurologic and psychiatric evaluations were negative, and blood pressure was 110/58.  On August 18, 2010, his blood pressure was 124/63.  

A September 16, 2010, report from Prince William Neurology Center shows that the Veteran had a history of nightmares but these had improved with his use of a CPAP device.  An October 19, 2010 record of Dr. K. Shareghi shows that blood pressure was 118/60 and on November 17, 2010, it was 130/68, and on both occasions neurologic and psychiatric evaluations were negative.  

A January 18, 2011 record of Dr. K. Shareghi shows that neurologic and psychiatric evaluations were negative, and the Veteran’s blood pressure was 140/70.  A February 16, 2011, record shows that his blood pressure was 132/62.   A March 2, 2011 consultation by the Ear, Nose & Throat Specialist of Northern Virginia shows that the Veteran complained of mild dysequilibrium when bending forward but that this was not unusual for someone who was 80 years old.  On examination his blood pressure was 140/70.  An April 18, 2011, record of Dr. K. Shareghi shows that neurologic and psychiatric evaluations were negative, and blood pressure was 140/70.  On May 18, 2011, his blood pressure was 106/54 and on August 17, 2011, it was 114/61.  

A September 15, 2011, report from Prince William Neurology Center shows that the Veteran had a history of deep venous thrombosis of the left lower extremity for which he used special stockings.  He has used a CPAP device since June 2010 for OSA.  In the past, he used to get nightmares.  As part of a neurology evaluation it was noted that the Veteran’s loss of olfactory sensation, history of nightmares in the past, and fear of falling suggested premotor symptoms of Parkinson’s disease.  A September 30, 2011 report from Potomac Urology shows that the Veteran had been treated for “BPH” and his blood pressure was 142/62.  A November 16, 2011, record shows that his blood pressure was 113/55.  

On February 15, 2012, the Veteran’s blood pressure was 130/59.  On February 20, 2012, his blood pressure was 156/76.  A February 28, 2012, record from the NOVA Orthopedic and Spine Center shows that the Veteran had had left ankle pain without injury for 2 weeks, and had a history of chronic DVT of the left leg.  A left ankle X-ray was negative but it was suspected he might have a stress fracture, and the assessments were pain and bursitis.  A March 8, 2012, report from Prince William Neurology Center shows that the Veteran was wearing an orthopedic boot on his left ankle, and he had had an avulsion injury of the left ankle joint.  Sensory examination was normal.  

An April 11, 2012 report from Potomac Urology shows that the Veteran’s blood pressure readings were 106/60 and 116/60.  On May 14, 2012, his blood pressure was 127/62.  An August 13, 2012, record shows his blood pressure was 137/61.  A September 7, 2012, report from Prince William Neurology Center shows that the Veteran’s low back pain had been stable and without any sciatica but he reported having had right foot weakness since his prior low back surgery.  His nightmares were better since using a CPAP device at home.  He had a normal gait and stance.  

A November 14, 2012, record shows that the Veteran’s blood pressure was 123/58; on November 21, 2012, it was 119/58; on November 26, 2012, it was 115/52; on December 6, 2012, it was 176/74; and on December 13, 2012, it was 142/66.  

A February 19, 2013, record shows that the Veteran’s blood pressure was 141/56.  A February 26, 2013 record from Prince William Neurology Center reflects that the Veteran had intermittent sciatica which lately had not bothered him too much.  On examination he had mild tandem ataxia but otherwise his gait and stance were normal.  

A March 7, 2013, record shows the Veteran’s blood pressure was 138/64.  A report of a March 20, 2013, ultrasound study shows the Veteran had a nonocclusive blood clot in the left peroneal and posterior tibial veins.  On May 21, 2013, his blood pressure was 113/60.  An August 15, 2013, EKG report shows that the Veteran’s blood pressure was 100/60.  An August 20, 2013, record shows that blood pressure readings were 97/51 and 96/50.  

An August 2013 report from Prince William Neurology Center shows that the Veteran was evaluated for, in part, hyposmia nightmares and OSA.  His blood pressure was 100/60.  On sensory examination there was decreased pinprick sensation over the anterolateral aspect of the right lower extremity and foot but his motor status was normal.  His gait was normal.  He had 90 degrees of lumbar flexion.  Straight leg raising was negative.  It was suspected that he might have pre-motor symptoms of Parkinson’s disease but the current examination did not reveal evidence of motor symptoms of Parkinson’s disease.  
A September 19, 2013, record shows the Veteran’s blood pressure was 136/62.  On September 25, 2013, he had a symptomatic right inguinal hernia.  He denied anxiety, depression, and insomnia.  Neurologically he denied dizziness, numbness, tingling and memory difficulties.  He was fully oriented.  His gait was steady.  A September 30, 2013, record shows his blood pressure readings were 105/50 and 101/54.  An October 14, 2013, office visit record shows that the Veteran’s blood pressure was 110/51.  The Veteran’s problem list included arthritis, bowel problems, deep vein thrombosis, diverticulitis, dizziness, gout, and hypertension.  

An October 28, 2013, record shows that the Veteran’s blood pressure was 77/41 and 85/47.  On November 20, 2013, his blood pressure was 115/55.  On March 13, 2014, his blood pressure was 122/59.  He had recently completed rehabilitation for mobility and his gait was unsteady.  A March 24, 2014, record shows that the Veteran needed physical therapy due to decreased strength in the right lower extremity, decreased balance, and gait abnormalities.  His functional limitation was right foot drop, and problems with ambulation and balance.  On June 12, 2014, it was reported that the Veteran had paresthesias of the lower extremities, and edema.  His blood pressure was 115/59.  On September 11, 2014, his blood pressure was 152/66 and 153/67.  On October 29, 2014, his blood pressure readings were 108/50 and 117/55.  

A November 24, 2014, record shows that the Veteran presented with gout.  His episodes of gout lasted for 2 days, and were manifested by aching in his left foot, and moderately limited his activities.  His blood pressure readings were 99/48 and 107/53.  The diagnosis was acute gouty arthropathy.  A November 23, 2014 report of doppler study of the left lower extremity revealed findings consistent with scarring from chronic nonocclusive deep venous thrombosis (DVT), like findings seen in November 2013.  On December 10, 2014, his blood pressure was 119/58. 

A February 10, 2015 record from Prince William Neurology shows that the Veteran had OSA and denied having sciatica and paresthesias but complained of progressive problems with his balance.  His blood pressure was 118/62.  On neurological evaluation he had mild difficulty arising from a seated position.  Deep tendon reflexes were absent in both ankles and 1+ at each knee.  His gait was remarkable for tandem ataxia.  Straight leg raising was negative, bilaterally.  

A March 9, 2015, record shows that the Veteran had injured his left knee 6 days earlier, and now had difficulty bearing weight and ambulating.  His blood pressure was 129/62.  A March 19, 2015, report of a night time polysomnogram from the Prince William Neurology & Sleep Disorders Center revealed mild OSA, and it was recommended that the Veteran use a CPAP device.  An April 17, 2015, record shows that the Veteran had injured his right knee 5 days earlier.  His blood pressure was 101/48.  At the time of a May 12, 2015, EKG his blood pressure was 128/68.  A June 1, 2015, record shows that the Veteran presented with hypothyroidism.  His blood pressure was 108/52.  A June 25, 2015, record shows that the Veteran complained of having constant left-sided low back pain for 2 months which was exacerbated by exertion and changing positions.  The pain sometimes radiated, and sometimes did not.  However, it was also noted that he denied having radicular pain in each leg.  He denied bladder incontinence and numbness and weakness of the extremities.  His blood pressure was 117/61.  On examination he had tenderness in the area of the lumbar spine.  Straight leg raising was normal but he had decreased range of motion in all planes (which was not reported in terms of degrees of motion).  Lumbar X-rays revealed stable multi-level degenerative changes.  

An August 17, 2015, record reflects that the Veteran had sought treatment at an emergency room for a contusion of his left leg.  His blood pressure was 101/48.  An August 19, 2015, cardiac study by Dr. Shareghi shows that the Veteran’s blood pressure was 183/76, prior to testing and 158/60 during testing.  A September 4, 2015, record shows that his blood pressure was 129/61.  The diagnoses included paresthesias of both feet, with onset of September 4, 2015.  

A September 17, 2015, record shows that the Veteran’s blood pressure readings were 93/44 and 98/44.  His problem list included insomnia, not otherwise specified, with onset in March 2015.  A November 14, 2015, record shows that his blood pressure was 155/69.  The diagnoses included benign prostatic hypertrophy (BPH) with urinary obstruction.  

Accrued Benefits

Accrued benefits are those benefits to which an individual was entitled at the time of death under existing ratings or decisions or based on the evidence in the file at the time of death, and which was due an unpaid at the time of death.  38 U.S.C. § 5121(a); 38 C.F.R. § 3.1000(a).  Upon the death of a Veteran, any accrued benefits are payable to his or her spouse, or to specific others, if the spouse is not alive.  38 U.S.C. § 5121(a)(2); 38 C.F.R. § 3.1000(a)(1).  In all other cases, only so much of the accrued benefits may be paid as may be necessary to reimburse the person who bore the expenses of last sickness and burial.  38 U.S.C. § 5121(a)(1-6); 38 C.F.R. § 3.1000(a).    

Principles of Service Connection

Service connection is warranted for disability incurred or aggravated during active service.  38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a).

Establishing service connection generally requires competent, credible evidence (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus, or link, between the current disability and in-service disease or injury.  See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009).  

Certain chronic diseases, such as arthritis and gouty arthritis, which are manifested to a compensable degree within one year of discharge from service discharge, shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service.  The presumption may be rebutted by affirmative evidence to the contrary.  38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.303(b), 3.307(a)(3), 3.309(a).

If a condition noted in service is not shown to be chronic, then generally a showing of continuity of symptomatology after service is required to support the claims. 38 C.F.R. § 3.303(b).  The theory of the continuity of symptomatology in service connection applies to those disabilities explicitly recognized as “chronic diseases” in 38 C.F.R. § 3.309(a).  Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013)

However, insomnia, as well as sleep apnea, are not chronic diseases listed at 38 C.F.R. § 3.309(a).  

Service connection may be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service.  38 C.F.R. § 3.303(d).

Service connection may be established on a secondary basis for: (1) a disability that is proximately due to or the result of a service-connected disease or injury; or, (2) any increase in severity of a nonservice-connected disease or injury which is proximately due to or the result of a service-connected disease or injury, and not due to the natural progression of the nonservice-connected disease or injury.  38 C.F.R. § 3.310(a)-(b).  To prevail on the theory of secondary service connection, there must be competent, credible evidence of (1) a current disability; (2) a service-connected disability; and (3) a nexus, or link, between the current disability and the service-connected disability.  Wallin v. West, 11 Vet. App. 509, 512 (1998).

The Board must determine whether the weight of the evidence supports each claim or is in relative equipoise, with the appellant prevailing in either event.  However, if the weight of the evidence is against the appellant’s claim, the claim must be denied.  38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski 1 Vet. App. 49 (1990).   

Issues 1 and 2 - Entitlement to service connection for a left and foot disorder, for accrued benefits purposes

The service treatment records (STRs) are negative for a disability of the Veteran’s feet.  In fact, he denied having foot trouble at separation from service.  He did not have week feet on VA general medical examination in 1970, and he again denied having foot trouble in medical history questionnaires while in the reserves in 1973, 1976, and as late as 1978.  

Beginning years after the Veteran’s active service there are three potential etiologies for symptomatology in the Veteran’s feet.  First, he is now service-connected for radiculopathy of each lower extremity, secondary to his service-connected low back disability.  This would include his reported right foot weakness following low back surgery in the 1980s and his more recently reported paresthesia of his feet, as related in private clinical records in 2015.  However, to the extent that the Veteran now has neurologic symptoms in his feet due to his service-connected radiculopathy of each lower extremity, it is compensated by the rating assigned for radiculopathy each lower extremity.  

Second, it is clear that the Veteran had gout, and in addition to affecting his right hand, it affected at least the 1st metatarsophalangeal (MTP) joint (great toe) of each foot, including arthritis of at least the left 1st MTP joint.  Of note is the fact that there is no contemporary evidence of gout prior to 1992, at which time it was noted that he had a history of gout but the length that history was not recorded.  However, a July 2006 private clinical record reported that gout had been diagnosis 20 years earlier, but even this history would not antedate his having had gout prior to 1986 which is a time more than a decade and a half after his active service.  Significantly, during his lifetime the Veteran never reported having had gout during his active service.  Accordingly, this evidence yields the conclusion that gout, including gout and gouty arthritis of the feet, was first manifested long after active service and is unrelated to military service.  

Third, it is also clear that the Veteran had circulatory disturbance in his lower extremities.  The earliest evidence of this does not antedate a private clinical notation of the recent onset of swelling in his legs due to venous insufficiency, which was then treated with diuretics.  Ultrasound and doppler studies, conducted many years after service, confirmed that the circulatory disturbance had been diagnosed as peripheral arterial disease (PAD) and peripheral vascular disease (PVD) and also confirmed the presence of deep venous thrombosis, and blood clotting.  However, there is no clinical evidence of any circulatory disease prior to 1992, more than 20 years after service and the Veteran during his lifetime never reported having had circulatory disturbance or disease during his active service.  Accordingly, it must be concluded that any circulatory disturbance in the Veteran’s lower extremities, including his feet, first manifested long after active service and is unrelated to military service.  

There is also evidence of acute post service injuries of the Veteran’s feet but these occurred many years after his active duty.  

For the foregoing reasons and bases, the Board must conclude that the preponderance of the evidence is against the claims for service connection for disorders of the Veteran’s feet. 

3.  Entitlement to service connection for sleep apnea, for accrued benefits purposes

STRs during the Veteran’s active service are negative for sleep apnea or any sleep disturbance.  In fact, a medical history questionnaire at the examination for discharge from active service shows that he denied having or having had frequent trouble sleeping.  Equally to the point is that there are no lay statements, not even from the Veteran during his lifetime, that he had any problems with his sleep during his active service.

As to this, the July 1970 VA examination noted that the Veteran reported that he sometimes awoke with a headache.  However, he is service-connected for headaches which have been evaluated as 10 percent disabling since he was discharged from service.  However, at the 1970 VA examination he did not report that his headaches caused him to awaken nor is this evidence of the impairment of his breathing during sleep which is characteristic of sleep apnea.  See 38 C.F.R. § 4.97, Diagnostic Code 6847.  

Thereafter, the earliest evidence pertaining the Veteran’s sleep is the March 1976 VA examination which noted that as part of a reactive depression in response to a divorce he felt depressed, lonely with sleep disturbance.  In this regard, only a few months later, a June 1976 medical history questionnaire in conjunction with an examination when he was in the reserves shows that he reported having or having had frequent trouble sleeping.  However, this evidence, in 1976, was many years after discharge from his active service and does not relate any sleep disturbance in 1976 to his military service years earlier, as opposed to being a possible reaction to a divorce.  

The earliest evidence of actual impairment of the Veteran’s breathing during sleep does not antedate 2010 when records of the Prince William Neurology Center show that he had a history of snoring and gasping for air when awakening.  Subsequently, polysomnograms confirmed the presence of OSA which necessitated his use of a CPAP device.  

So, it must be concluded that any OSA first manifested long after active service and is unrelated to military service.  For these reasons and bases, the Board must conclude that the preponderance of the evidence is against the claim for service connection for sleep apnea.  

4.  Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, for accrued benefits purposes

For claims for service connection for PTSD the record must include (1) medical evidence diagnosing PTSD; (2) a link, established by medical evidence, between a Veteran's present symptoms and an in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor actually occurred.  38 C.F.R. § 3.304.

Here, the record does not reflect nor does the Veteran does not contend that he was diagnosis of PTSD during service, engaged in combat, was a prisoner-of-war, or experienced an event related to a fear of hostile military or terrorist activity.  See 38 C.F.R. § 3.304(f)(1), (2), (3), and (4).  As such, neither Veteran nor anyone else ever described any incident or event, or combination of incidents or events, as being a putative stressor(s).  

Absent evidence of an in-service stressor or stressors, there can be no probative diagnosis of PTSD; and as in this case, there has never been a diagnosis of PTSD.  In this regard, as to the Veteran’s having had nightmares, these are first shown to have existed only at a time many years after service and, more to the point, there is nothing in the record which indicates that the Veteran ever described the nightmares or otherwise even suggests that the nightmares are related in any way to military service, including any putative stressor(s).  Although there is evidence which suggests that impaired oxygen intake due to sleep apnea had an impact of the severity of the nightmares, this does not relate the nightmares to military service.  

As to some other form of acquired psychiatric disorder being of service origin, the STRs during active service are completely negative for signs or symptoms of psychiatric disability.  In fact, the medical history questionnaire in conjunction with the examination for separation from active service shows that he denied having or having had frequent or terrifying nightmares; depression or excessive worrying; loss of memory or amnesia; nervous trouble of any sort; or excessive drinking habit.  

Only three months after service, on VA neuropsychiatric examination in July 1970 the Veteran had no complaints of a psychiatric nature and while he described himself as driven, the examiner did not consider him to be a compulsive person, and there was no psychiatric diagnosis because he did not exhibit psychiatric material.  

Almost six years after service, on VA examination in March 1976 the Veteran complained of frequent headaches which, when severe, were accompanied by extreme nervousness.  He was obsessive and anxious but cooperative and he had reactive depression in response to recent domestic difficulties due to a divorce.  He felt depressed and lonely, and the examiner suggested that the Veteran seek counseling.  This reaction to his divorce apparently continued inasmuch as a medical history questionnaire on examination in June 1976, in the Air Force Reserves shows that he was taking Valium and he reported having or having had depression or excessive worrying but he denied having or having had loss of memory or amnesia; nervous trouble of any sort. 

However, two years later, a medical history questionnaire in October 1978 on examination in the Air Force Reserves shows he reported not having or having had frequent trouble sleeping; frequent or terrifying nightmares; depression or excessive worrying; loss of memory or amnesia; nervous trouble of any sort.  

Thus, the evidence does not show that the Veteran’s 1976 complaints and symptoms in response to a divorce were anything other than acute and transitory, having resolved by 1978, and while he was given Valium there was no diagnosis of an acquired psychiatric disorder.  Likewise, the single and isolated complaint of having extreme nervousness when having a severe headache does not establish that the Veteran had a chronic acquired psychiatric disorder which was either caused or aggravated by his service-connected headache.  

Many years after service a private clinical record of Dr. C. Azzam in 2014 shows the Veteran complained of anxiety.  However, repeated post service evaluations by Dr. Shareghi, and at the Cardiac Care Center reflect that the psychiatric evaluation results were negative.  

For these reasons and bases, the Board must conclude that the preponderance of the evidence is against the claim for service connection for an acquired psychiatric disorder, to include PTSD.  


5.  A rating higher than 40 percent for lumbar DDD with spondylolysis and spinal stenosis, for accrued benefits purposes

Under the Diagnostic Code (DC) 5243, intervertebral disc syndrome (IVDS) is rated either on the total duration of incapacitating episodes over the past 12 months or by combining separate evaluations of the chronic orthopedic and neurologic manifestations, whichever method results in the higher rating. 

As to incapacitating episodes, a maximum 60 percent rating is warranted if there are incapacitating episodes having a total duration of at least six weeks during the past 12 months.  The IVDS rating criteria do not provide for an evaluation higher than 60 percent on the basis of the total duration of incapacitating episodes.  

Note 1 to the DC 5243 defines an incapacitating episode as a period of acute signs and symptoms that requires bed rest prescribed by and treatment by a physician.  Supplementary Information in the published final regulations states that treatment by a physician would not require a visit to a physician's office or hospital but would include telephone consultation with a physician.  If there are no records of the need for bed rest and treatment, by regulation, there are no incapacitating episodes.  67 Fed. Reg. 54345, 54347 (August 22, 2002).   

In this case, there is no evidence of no records of the need for treatment and bed rest prescribed by a physician as to either the Veteran’s service-connected cervical spine disability or his thoracolumbar spine disability.  Since the Veteran had never been prescribed bed rest by a physician, he cannot have had "incapacitating episodes" within the meaning of the rating criteria in the Formula for Rating IVDS Based on Incapacitating episodes at 38 C.F.R. § 4.71a, Diagnostic Code 5243.  It necessarily follows that the appropriate ratings may be assigned only for the orthopedic manifestations, with separate ratings assigned for any associated peripheral nerve disability(ies). 

As for rating the orthopedic manifestations, the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula) is used and encompasses symptoms such as pain (radiating or not), stiffness, and aching but does not require that there be such symptoms for any particular rating.  68 Fed. Reg. at 51454 - 51455 (August 27, 2003). 

Under the general rating formula, a 40 percent rating is warranted for limited thoracolumbar motion when forward flexion is to 30 degrees or less; or, there is favorable ankylosis of the entire thoracolumbar spine; a 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine; and a 100 percent for unfavorable ankylosis of the entire spine. 

In this case the evidence does not show that the Veteran ever had ankylosis, either favorable or unfavorable, of the entire thoracolumbar spine or the entire spine.  Consequently, the preponderance of the evidence is against the assignment of a schedular rating in excess of 40 percent as of October 13, 2014.

Issues 6 and 7 - A higher initial rating for radiculopathy of the left and right lower extremities, each rated 10 percent, for accrued benefits purposes
  
Under 38 C.F.R. § 4.124a, the schedules for rating diseases of the cranial and peripheral nerves include alternate diagnostic codes for paralysis, neuritis, and neuralgia of each nerve.  See 38 C.F.R. § 4.124a, Diagnostic Codes 8205 to 8730.  Peripheral neuropathy which is wholly sensory is mild or, at most, moderate.  With dull and intermittent pain in a typical nerve distribution, it is at most moderate.  With no organic changes it is moderate or, if of the sciatic nerve, moderately severe.  38 C.F.R. § 4.20.  Neuralgia of a peripheral nerve of a lower extremity can receive a maximum rating of moderate incomplete paralysis.  38 C.F.R. § 4.124.  Neuritis characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, can receive a maximum rating of severe, incomplete paralysis.  38 C.F.R. § 4.123.  

Sciatic neurological manifestations are rated under Diagnostic Code 8520, 8620, or 8720 as, respectively, paralysis, neuritis or neuralgia of the sciatic nerve.  The criterion for a 10 percent rating is mild incomplete paralysis.  The criterion for a 20 percent is moderate incomplete paralysis and 40 percent when moderately severe.  When severe with marked muscular atrophy, 60 percent is warranted and 80 percent is warranted for complete paralysis (with foot drop, no active movement possible below the knee, and weakened or, very rarely, lost knee flexion).  See also 38 C.F.R. § 4.124a, Diagnostic Codes 8620, 8720 (for sciatic neuritis and neuralgia).  

Considering first the left lower extremity, the private clinical records in June and July 2014 show that the Veteran complained of moderate weakness of his legs.  Nevertheless, on each occasion a private physician found that the Veteran had no weakness.  Moreover, it must be noted that in June 2014 he reported that such weakness had begun only about 5 years earlier after he developed blood clots in his legs.  However, the Veteran is not service-connected for any circulatory disorder in either leg.  

The April 2015 VA examination found that the Veteran had radicular symptoms in the left lower extremity which were described as moderate numbness, and severe pain and paresthesia.  This is consistent with the private electrodiagnostic testing done in June 2014 which found sensory as well as motor neuropathy.  The private examinations by Dr. Azzam found that sensation was intact to touch and reflexes were normal, and similarly the April 2015 VA examination found that reflexes were normal as was strength but that sensation was decreased.  

Given these findings, the Board concludes that the level of severity of the sciatic neuropathy in the Veteran’s left lower extremity was moderate in severity and warranted a 20 percent disability rating.  However, in light of his having normal reflexes, no muscular atrophy, and no organic changes the Board finds that the left lower extremity radiculopathy did not more closely approximate the criteria for the next higher rating of 40 percent for moderately severe sciatica neuropathy.

Considering next the right lower extremity radiculopathy, the private clinical records in June and July 2014 show that the Veteran complained of moderate weakness of his legs but on each occasion a private physician found that the Veteran had no weakness.  Moreover, it must be noted that in June 2014 he reported that such weakness had begun only about 5 years earlier after he developed blood clots in his legs.  However, the Veteran is not service-connected for any circulatory disorder in either leg.  
Electrodiagnostic testing in June 2014 found evidence of sensory and motor impairment, and this is in keeping with the Veteran’s history of having had some right foot drop.  He also has complaints of radicular sensory symptoms in the right leg of pain, paresthesia, and numbness but the sensory component in the right leg is less than that in the left leg.  However, given these findings, and particularly the history of right foot drop, the Board finds that the level of severity of the sciatic neuropathy in the right lower extremity was moderate in severity and warranted a 20 percent disability rating.  However, in light of his having normal reflexes, no muscular atrophy, and no organic changes the Board finds that the right lower extremity radiculopathy did not more closely approximate the criteria for the next higher rating of 40 percent for moderately severe sciatica neuropathy.  



8.  A rating in excess of 10 percent for hypertension, for accrued benefits purposes

The Veteran’s service-connected hypertension was rated under 38 C.F.R. § 4.104, Diagnostic Code 7101.  For a minimum 10 percent rating diastolic blood pressure must be predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control.  

For the next higher schedular rating of 20 percent diastolic blood pressure must be predominantly 110 or more; or systolic blood pressure must be predominantly 200 or more.  Note (3) to Diagnostic code 7101 provides that hypertension is to be rated separately from hypertensive heart disease and other types of heart disorders.  

To the extent that the Veteran has cardiac complications due to hypertension, such complications are encompassed under 38 C.F.R. § 4.104, Diagnostic Code 7007 (hypertensive heart disease) as part of his service-connected cardiovascular disorder which was assigned a 100 percent schedular rating as of 10 schedular rating as of October 13, 2014 (date of receipt of his claim for increased ratings).  

The Veteran’s use of medication for control of hypertension is encompassed in the 10 percent rating assigned for that disorder.  For the next higher rating of 20 percent, he would have to have diastolic blood pressure must be predominantly 110 or more; or systolic blood pressure must be predominantly 200 or more.  

The Board has reviewed the entire evidentiary record, including all blood pressure readings since the Veteran’s discharge from active service.  This review demonstrates that even for the period prior to one year before receipt of his October 13, 2014, claim for increase, as well as thereafter, he never had diastolic blood pressure readings of predominantly 110 or more; or systolic blood pressure readings of predominantly 200 or more.  

Consequently, the Board must conclude that the preponderance of the evidence is against the claim for a rating in excess of 10 percent for hypertension, for the purpose of accrued benefits.  

9.  An initial compensable rating for a post-operative lumbosacral scar, for accrued benefits purposes

The Veteran’s PO lumbosacral scar is not on an exposed area and is not demonstrated to be depressed, adherent or associated with underlying soft tissue, tender, painful, unstable or otherwise symptomatic.  This single scar does not cover an area exceeding 12 square inches and does not affect motion of the thoracolumbar spine or otherwise impair function of the Veteran’s low back or have any disabling effect.  See 38 38 C.F.R. § 4.118, Diagnostic Codes 7801-7802, 7804-7805.  

(Continued on the next page)
 
Thus, the Board must conclude that the preponderance of the evidence is against the claim for an initial compensable rating for a PO lumbosacral scar, for the purpose of accrued benefits.
 
DEBORAH W. SINGLETON
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	Department of Veterans Affairs