Citation Nr: 18159459 Decision Date: 12/20/18 Archive Date: 12/19/18 DOCKET NO. 17-45 219 DATE: December 20, 2018 ORDER Entitlement to service connection for left lower extremity pain and numbness is granted. FINDING OF FACT The evidence is at least in equipoise as to whether the Veteran’s service-connected diabetes caused his left lower extremity pain and numbness. CONCLUSION OF LAW The criteria for service connection for left lower extremity pain and numbness secondary to service-connected diabetes have been satisfied. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 1969 to June 1975, to include service in the Republic of Vietnam. This matter comes before the Board of Veterans’ Appeals (Board) from a June 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Board referred this case for a Veteran’s Heath Administration (VHA) opinion. The Veteran was provided a copy of that decision and allowed time for response. Generally, to establish service connection, a claimant must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called “nexus” requirement. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303; see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). A disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. Ultimately, the Veteran is seeking service connection for left lower extremity pain and numbness. See Statement from Veteran dated November 4, 2014; see also Clemons v. Shinseki, 23 Vet. App. 1 (2009). He initially asserted that these symptoms were nerve damage resulting from a prostatectomy. However, the Board finds that service connection is actually warranted on a different basis; specifically, the claimed disability is caused by the Veteran’s service-connected diabetes. In April 2015 and April 2018, VA examiners found that there was no medical evidence of diabetic peripheral neuropathy to account for the left lower extremity symptoms. However, the Board subsequently requested a VHA opinion to determine if the Veteran’s left lower extremity pain and numbness was due to his prostatectomy, and in June 2018 the VHA examiner concluded that the Veteran’s lower extremity pain and numbness is an early manifestation of insidious onset diabetic neuropathy exacerbated by hypertension, vascular disease, and decades of tobacco and alcohol abuse. Her rationale was that diabetic polyneuropathy may be identified before the patient is even aware of having diabetes. She continued that the bilateral symmetrical reduction in position sense in all extremities is a subjective but telling finding, in that position sense is mediated by large nerve fibers that are especially sensitive to metabolic and vascular disturbance of diabetes and hypertension. This opinion puts the evidence at least into equipoise as to whether the left lower extremity pain and numbness are caused by the Veteran’s service-connected diabetes. As such, service connection for left lower extremity pain and numbness is granted on a secondary basis. 38 C.F.R. § 3.310; see also Saunders v. Wilkie, 886 F.3d 1356, 1367-68 (Fed. Cir. 2018). The evidence is against a finding of any nerve damage resulting from the Veteran’s prostatectomy in July 1995. There is no competent evidence in the record of there being nerve damage during the Veteran’s prostatectomy and the Veteran did not report any numbness after the surgery. Although there are reports of leg cramps in 1995, the Veteran’s treatment records show that the Veteran had this prior to the prostatectomy. The Veteran failed to report any lower extremity numbness during his 1999 follow up with urology. After the Veteran had a cyst removed from his spine in October 2009, he found some relief from his left leg numbness. The Veteran did not report numbness again until a few years later, at which point he was found to have degenerative disc disease that was causing lower extremity radiculopathy. In addition to this diagnosis, the VHA opinion states that the left lower extremity neuropathy is not a result of a surgery that occurred over 20 years ago, and was more likely to be a result of an early manifestation of insidious onset diabetic neuropathy exacerbated by hypertension, vascular disease, and decades of tobacco and alcohol abuse. Neither opinion nor treatment records attribute the Veteran’s left lower extremity symptoms to his prostatectomy that occurred over 20 years ago. (Continued on the next page) Service connection for left lower extremity pain and numbness was first claimed as being a residual of a prostatectomy. While service connection is not warranted on that basis, the Board finds that service connection is warranted on a secondary service connection basis as the evidence is at least in equipoise as to whether the claimed disability is secondary to the Veteran’s service-connected diabetes. As such, the claim is granted. Nathan Kroes Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Megan Shuster, Law Clerk