Citation Nr: 1812924 Decision Date: 03/01/18 Archive Date: 03/13/18 DOCKET NO. 15-30 993 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUES 1. Entitlement to service connection for a disability manifested by swelling, pain, weakness, instability, and jerking movements of the left lower extremity (other than venous insufficiency of the left lower extremity and post-surgical neuropathy of the left lower extremity), to include arterial insufficiency of the left lower extremity. 2. Entitlement to service connection for a disability manifested by swelling, pain, weakness, instability, and jerking movements of the right lower extremity (other than right left edema), to include arterial insufficiency of the right lower extremity. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD Tiffany N. Hanson, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Navy from November 1962 to December 1982. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. The Veteran perfected a timely appeal. See Notice of Disagreement, dated September 2014, Statement of the Case, dated July 2015 and Substantive Appeal (VA Form 9), dated August 2015. In November 2017, the Veteran and his wife testified at a videoconference hearing before the undersigned Veterans Law Judge (VLJ). The transcript of the hearing is of record. The Board notes that the Veteran's complaints regarding his left and right lower extremities were previously characterized, in September 2013 at which time he filed his claims, as swollen left extremity and right extremity, respectively. However, based on the evidence of record, to include the Veteran's lay statements, the claims have been recharacterized as seen on the title page. See Brokowski v. Shinseki, 23 Vet. App. 79 (2009); Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Board reviewed the Veteran's electronic claims file which includes records in Virtual VA and Veterans Benefits Management System (VBMS) databases prior to rendering its decision. The issues of entitlement to an increased rating for:(1) venous insufficiency of the left lower extremity, rated 20 percent disabling; (2) right leg edema, rated noncompensable (0 percent); and (3) post-surgical neuropathy of the left lower extremity, rated noncompensable (0 percent), have been raised by the record in testimony presented at the November 2017 hearing, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). As such, these issues are referred to the AOJ for appropriate action in accordance with the regulations that govern the filing of claims. 38 C.F.R. §§ 3.150, 3.155, 19.9(b) (2017). 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). FINDINGS OF FACT 1. The evidence of record contains medical guidance explaining that the signs or symptoms characteristic of swelling and edema of the right and left lower extremities, as shown by examination, are related to the known clinical diagnosis of service-connected right leg edema and venous insufficiency of the left lower extremity. 2. The evidence of record contains medical guidance explaining that the signs or symptoms characteristic of numbness and decreased sensation to light touch in the left lower extremity, as shown by examination, are related to the known clinical diagnosis of service-connected post-surgical superficial neuropathy of the left lower extremity. 3. The evidence of record contains medical guidance explaining that the signs or symptoms characteristic of claudication of the right and left lower extremities, as shown by examination and Doppler ultrasound, are related to the known clinical diagnosis of arterial insufficiency of the right and left lower extremities. 4. The evidence of record establishes that the Veteran's arterial insufficiency of the right and left lower extremities, which is manifested by signs and symptoms characteristic of claudication, did not begin in service and is not proximately due to an injury or disease of service origin. CONCLUSION OF LAW 1. The criteria for establishing service connection for a disability manifested by swelling, pain, weakness, instability, and jerking movements of the left lower extremity (other than venous insufficiency and post-surgical neuropathy of the left lower extremity), to include arterial insufficiency of the left lower extremity, have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). 2. The criteria for establishing service connection for a disability manifested by swelling, pain, weakness, instability, and jerking movements of the right lower extremity (other than right leg edema), to include arterial insufficiency of the left lower extremity, have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and Assist With respect to the Veteran's claims, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2017). VA's duty to notify was satisfied by a letter dated in December 2013. See 38 U.S.C. §§ 5103, 5103A; 38 C.F.R. § 3.159; see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). With respect to the duty to assist, the service treatment records, VA outpatient treatment records and examinations, identified private records, and statements from the Veteran and his spouse have been obtained. Additionally, the Veteran and his spouse testified at a hearing before the Board, and a transcript of the hearing is of record. The Veteran has not identified any additional, existing evidence that has not already been obtained and associated with the claims file. Accordingly, the Board finds that VA has satisfied its duty to assist. II. Service Connection Service connection is warranted where the evidence of record established that a particular injury or disease resulting in disability was incurred in or aggravated in the line of duty in active military service or, if preexisting such service, was aggravated thereby. 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 a disease or injury, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). 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 the severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to natural progress of the nonservice-connected disease or injury. 38 C.F.R. § 3.310(a), (b); see also Harder v. Brown, 5 Vet. App. 193, 197 (1993) (explaining the 38 C.F.R. § 3.310(a)); Allen v. Brown, 7 Vet. App. 439, 448 (1995) (explaining 38 C.F.R. § 3.310(b)). The Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the Veteran's claims and what the evidence in the claims file shows, or fails to show, with respect to those claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). III. Background and Analysis The Veteran contends that he is entitled to service connection for a disability manifested by pain, swelling, weakness, and jerking movements of the left and right lower extremities. In this regard, the Board notes that the evidence does not reflect and the Veteran does not allege that such disability had its onset in service. His primary contention is that this disability is secondary to his service-connected heart disease. By way of background, the Board observes that service connection is currently in effect for myocardial infarction with aortic valve replacement and coronary artery bypass surgery graft (heart disease). Service connection has also been established for venous insufficiency of the left lower extremity, post-surgical superficial neuropathy of the left lower extremity, and right leg edema, all of which are secondary to the service-connected heart disease. In a rating decision, dated in October 2009, the Veteran established service connection venous insufficiency of the left lower extremity and post-surgical neuropathy of the left lower extremity, each as secondary to the service-connected heart disease. With respect to the service-connected venous insufficiency of the left lower extremity, the RO noted that the objective findings showed persistent edema, incompletely relieved by elevation of the extremity. More specifically, at the July 2009 VA examination, the Veteran reported experiencing persistent, moderate left leg swelling, to include pitting edema; the diagnosis was of residual venous insufficiency of the left leg, as a complication of the saphenous vein graft harvest. See September 2014 Statement from R.D.L.R., M.D (swelling and edema of the left lower extremity is due to venous harvesting surgical procedure on the left lower extremity). With respect to the service-connected post-surgical neuropathy of the left lower extremity, the RO noted that the objective findings showed mild neuropathy of the left lower extremity. At the July 2009 VA examination, the Veteran reported experiencing numbness in the left leg, and the examination revealed decreased sensation to light touch in the area distal to his vein donor site; the diagnosis was of mild post surgical superficial neuropathy, which was not following any particular nerve or dermatonal pattern, related to the saphenous vein graft harvest. In statements submitted in September 2013, the Veteran contended, in essence, that he had edema in his legs and described weakness and numbness in his legs as if there was no strength to bear his body weight. He further maintained that he had involuntary movements of his legs, to include, on occasion, his entire body. In a letter dated in October 2013, provided by the Veteran's wife, she stated that the Veteran had chronic, frequent, involuntary jerking or movement of his lower extremities that sometimes involved his whole body. At the Board hearing, the Veteran testified to the effect that while his bilateral lower extremity disorder was manifested by swelling in his left and right lower extremities, it was also accompanied by weakness, pain, instability, and jerking movements. His wife also testified that he uses assistive devices and her shoulder for stability, that he avoids stairs, and that he exhibits jerking movements when he is asleep. See Board Hearing Transcript (November 2017). Service connection was established for right leg edema as secondary to the service connected heart disease in a November 2017 rating decision. This determination was based on an October 2017 medical opinion providing that the Veteran developed bilateral leg edema which is secondary to his service-connected heart disease; and a November 2017 medical opinion providing that there is no relationship between the bilateral leg edema and the service-connected heart disease. See September 2015 Statement R.D.L.R., M.D. (swelling and edema of the right and left lower extremities is due to venous harvesting surgical procedure). Because the medical evidence was in equipoise, it formed the basis to establish service connection for the right leg edema on a secondary basis. In order to avoid the practice of pyramiding (providing multiple disability ratings for the same disability under various diagnoses), the Board shall not consider granting service connection for symptomatology impacting the lower extremities already contemplated under Diagnostic Codes 7121 and 8727 - all of which the Veteran is service connected. 38 C.F.R. § 4.14. At the outset of the November 2017 hearing, the Veteran and his representative asserted that the Veteran has experienced swelling in his left and right lower extremities. The Veteran and his representative also were of the understanding that the manifestation of edema, which is swelling, is contemplated by the Diagnostic Code 7121 for which the Veteran has already been service connected and rated for venous insufficiency of the left lower extremity and right leg edema. Similar to the manifestation of swelling, as discussed above, the Board finds that the manifestations of numbness and decreased sensation in the left lower extremity are specifically contemplated under, and are characteristic of Diagnostic Code 8727 (post-surgical neuropathy of the left lower extremity), for which the Veteran is already service connected. Again, Diagnostic Code 8727 encompasses symptomatology marked by nerve impairment. In their submitted statements and testimony, the Veteran and his wife have further attested that he has experienced pain, weakness, instability, and jerking movements of the right and left lower extremities. This same symptomatology was evaluated in August 2007, during neurological consultation. At that time, the Veteran reported bilateral leg weakness, tingling in his calves and feet, intermittent giving out of his legs, particularly in the calves, and a feeling that he was losing power associated with numbness in the calves, as well as involuntary movements of his left leg at nighttime, which he described as twitching. Although neurological testing indicated a possibility of lumbosacral radiculopathy, subsequent diagnostic data in January 2010, a duplex ultrasound for bilateral leg claudication, were interpreted as showing arterial insufficiency in the right and left lower extremities due to atherosclerosis. By definition, claudication is cramping pain and weakness in the legs especially in the calves on walking associated with an inadequate supply of blood to the muscles. Http://www.merriam-webster.com/medical/intermittent%20claudication (Merriam-Webster Medical Dictionary). In this regard, when the Veteran was examined by VA for conditions of the heart, artery, and veins in January 2014, the examiner noted that the Veteran had a Doppler ultrasound for bilateral leg claudication in January 2010; the result of which showed significant arterial insufficiency in both the right and left lower extremities due to atherosclerosis. The examiner noted a diagnosis of peripheral artery disease of the bilateral lower extremities, which was based on the clinical findings from the Doppler ultrasound, and noted that the severity of the symptoms included claudication on walking, and diminished peripheral pulses. According to the VA examiner, the diagnosis of peripheral artery disease, shown as arterial insufficiency of the bilateral lower extremity on Doppler ultrasound, is an illness independent from coronary artery disease, myocardial infarction, and venous insufficiency. The Board does not dispute the fact the Veteran currently has arterial insufficiency of the bilateral lower extremities. However, the Board finds that the January 2014 VA examiner's opinion to be highly probative. Here, the January 2014 VA examiner's conclusion is based upon a thorough review of the record, physical examination of the Veteran, and acknowledgement of the Veteran's and his spouse's statements regarding nature of his symptoms. Moreover, the opinion is supported by a sufficient explanation and reference to pertinent evidence of record. See Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) (VA examination report "must be read as whole" to determine the examiner's rationale). Furthermore, the examiner fully considered the Veteran's reports regarding his symptoms including bilateral leg pain and weakness and reconciled his symptoms with the other evidence of record. See Nieves-Rodgridquez, 22 Vet. App. 22 Vet. App. 295, 304 (2008) (holding, in the context of weighing one medical opinion with another, that "[i] is factually accurate, fully articulated, sound reasoning for the conclusion . . . that contributes probative value to the medical opinion). In this regard, the VA examiner reviewed the Veteran's record and the lay statements and testimony regarding the possible relationship between the Veteran's arterial insufficiency of the bilateral lower extremities and his service-connected heart condition; however, the examiner sufficiently explained why the Veteran's arterial insufficiency of the bilateral lower extremities was nonetheless not related to his coronary artery disease, myocardial infarction, and venous insufficiency, and was related to peripheral manifestations of atherosclerosis, specifically peripheral artery disease. Moreover, the medical statements from R.D.L.R., M.D., in September of 2014 and 2015, only address the etiology of the Veteran's swelling in the right and left lower extremities, for which service connection on a secondary basis has already been established. As such, the Veteran has not submitted any evidence or any private medical opinions that would be at variance with the January 2014 VA examiner's conclusions. Accordingly, the Board acknowledges that the Veteran's statements on the issue of the cause of his arterial insufficiency of the bilateral lower extremities are relevant even though its probative value may be slight. In this case, the Veteran and his spouse (who is a retired registered nurse) believe that his arterial insufficiency of the bilateral extremities, which manifests symptoms characteristic of claudication, can be attributed to his service-connected heart disease. However, as discussed above, the causes of his condition are medically complex and may develop for reasons that are not subject to the Veteran's lay observation. While the Veteran's spouse possesses the medical knowledge, training, and skill set of a registered nurse, the record does not indicate that she has otherwise provided a rationale, in terms of the objective clinical data of record, in formulating her belief and/or conclusion. Hence, the Board finds statements from the Veteran and his spouse to be of minimal probative value compared to the January 2014 VA examination report, including the diagnostic studies discussed therein, against the claims. While the Board is sympathetic to the Veteran's claims, taking into account all of the relevant evidence of record, the preponderance of the evidence is against a finding of an etiological relationship between the Veteran's arterial insufficiency of the bilateral lower extremities (which is manifested by signs and symptoms characteristic of claudication) and his military service and his service-connected coronary artery disease, myocardial infarction, and venous insufficiency. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the- doubt doctrine. However, as the preponderance of the evidence is against the claims, that doctrine is not applicable. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The appeal is denied. ORDER Entitlement to service connection for a disability manifested by swelling, pain, weakness, instability, and jerking movements of the left lower extremity (other than venous insufficient of the left lower extremity and post-surgical neuropathy of the left lower extremity), to include arterial insufficiency of the left lower extremity, is denied. Entitlement to service connection for a disability manifested by swelling, pain, weakness, instability, and jerking movements of the right lower extremity (other than right left edema), to include arterial insufficiency of the right lower extremity, is denied. ____________________________________________ DEBORAH W. SINGLETON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs