Citation Nr: 21061655 Decision Date: 10/04/21 Archive Date: 10/04/21 DOCKET NO. 14-24 993 DATE: October 4, 2021 ORDER Entitlement to service connection for a bilateral leg condition, to include peripheral vascular insufficiency and peripheral neuropathy, is denied. FINDING OF FACT The preponderance of the evidence is against finding that a bilateral leg condition to include peripheral vascular insufficiency and peripheral neuropathy began during active service or is otherwise related to an in-service injury or disease or manifested within one year after discharge. CONCLUSION OF LAW The criteria for service connection for a bilateral leg condition to include peripheral vascular insufficiency and peripheral neuropathy have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from August 1961 to August 1963. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2010 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA). The Board finds there has been substantial compliance with the April 2019 remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900 (c), 38 U.S.C. § 7107 (a)(2). Entitlement to service connection for a bilateral leg condition to include peripheral vascular insufficiency and peripheral neuropathy is denied. The Veteran contends his bilateral leg condition, including peripheral vascular insufficiency and peripheral neuropathy, is due to his active service. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303 (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 for a disability requires evidence of: (1) a current disability; (2) a disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Certain chronic diseases, including organic diseases of the nervous system, may be service connected on a presumptive basis if manifested to a compensable degree in a specified period of time post-service (one year for organic diseases of the nervous system). 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. The Veteran's bilateral lower extremity peripheral neuropathy and vascular disease are well document. He reported incurring cold weather injuries during service in Korea. Shedden elements (1) and (2) are met. Turning to element (3), a nexus, an April 2015 VA examiner opined the Veteran's disability was less likely than not due to service. She explained that the first complaint of a bilateral leg disability was on November 9, 2001, approximately 38 years after discharge. The examiner stated there are many etiologies for sensory axonal neuropathy, however, given the time frame of the presentation of the Veteran's symptoms, she could not conclude that his disability was caused by cold exposure during service. A May 2015 VA examiner also determined the Veteran's disability was less likely related to active service. He explained there was no etiological correlation between direct exposure to cold weather and peripheral vascular disease. Rather, cold temperatures may result in frostbite (necrotic tissue) due to reduced blood. However, there the examiner did not find evidence of a current frostbite disability. The Board requested a specialist's opinion. Dr. J.G., M.D. submitted a detailed medical report in April 2018. Dr. J.G. opined it was less likely than not that the Veteran's bilateral lower extremity peripheral neuropathy was due to service or had its onset within one year of separation. He explained that cold injury is characterized by impaired control of circulation and direct damage to the microcirculation; usually associated with being wet and cold. Extremities pass through four stages of injury which include: loss of sensation during cold exposure and the extremity appears white and numb; the extremity then appears mottled and pale blue from a few hours to days; the extremity then becomes bright red and edematous with bounding pulses, delayed capillary refill, and intense pain; and finally, the last stage may last from weeks to years which includes symptoms such that the extremity is very sensitive to cold, feels cold, is usually painful, has hyperhidrosis, and may exhibit complex regional pain syndrome. In severe cases, there is tissue necrosis which results in amputation. Dr. J.G. referenced a UK study of 42 individuals who served in the UK military and had cold injury. All participants had painful feet and hands, usually in a stock-glove distribution and cold hypersensitivity. Dr. J.G. found no evidence the Veteran exhibited any of the stages of cold injury including skin changes or painful conditions of the feet or lower extremities. Dr. J.G. stated if the Veteran had suffered any of these changes, he would have required medical evaluation and would not be able to perform his military duties during this acute phase. Dr. J.G. also stated it was less likely than not that the Veteran's mild bilateral venous insufficiency had its onset in military service. He explained the Veteran has no appreciable arterial insufficiency. Mild venous insufficiency was found in 2012 when the Veteran was almost 69 years old. Dr. J.G. stated that vascular damage would not be limited to mild venous insufficiency. Instead, there would be microcirculation damage and arterial circulation damage. Typically, cold induced vascular changes lead to thromboembolism and endothelial damage. Such is not the case with this Veteran. The Veteran has had no issues with cool extremities or skin changes which should be present if the Veteran had cold weather induced injuries to his lower extremities. The Board finds that the preponderance of the evidence is against granting the Veteran's claim of service connection for bilateral leg condition, including peripheral vascular insufficiency and peripheral neuropathy. The Board affords Dr. J.G.'s April 2018 opinion great weight, as it was based on medical principles, adequate rationale and supported by medical evidence of record. Importantly, the examiner considered the Veteran's lay statements and history of symptom manifestation. See Dalton v. Nicholson, 21 Vet. App. 23 (2007). The Board assigns significant probative weight to the April 2018 expert medical report because not only is it factually accurate and fully articulate, but Dr. J.G. thoroughly reviewed the claims file, considered the Veteran's contentions and provided comprehensive rationale discussing why the claimed disabilities were not a result of active service. The Board has considered the Veteran's contention that Dr. D.S.Q.'s medical notes and a March 2017 Disability Benefits Questionnaire (DBQ) support his claim for service connection. However, the Board finds that treatment notes and the DBQ do not provide an opinion regarding etiology of the Veteran's claimed disabilities. Specifically, the notes and DBQ are solely based on the Veteran's reports his current disability occurred during service. The Board finds that March 2017 DBQ is inadequate because it only contained data without an opinion regarding etiology or rational in support of the claim. Inadequate medical examinations include examinations that contain only data and conclusions, do not provide an etiological opinion, are not based upon a review of medical records, and/or provide unsupported conclusions. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Thus, March 2017 DBQ is inadequate, is of low probative value and is inadequate to support a grant of entitlement to service connection of the claim. Organic disease of the nervous system (peripheral neuropathy) may be granted service connection on a presumptive basis under 38 C.F.R. § 3.309 (a) if manifested to a compensable degree within 1 year of separation from service. The presumption does not apply in the Veteran's case because the preponderance of the evidence shows peripheral neuropathy did not manifest within one year of discharge. Moreover, treatment records, VA examination reports, and the April 2018 expert report do not show a continuity of symptomatology. As such, the evidence does not support a finding of continuity of symptomatology under 38C.F.R. §3.303(b). There is no indication that the Veteran is competent to etiologically link any symptoms to service or a service-connected disability. He is not shown to possess the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation. Nothing in the record demonstrates that he received any special training or acquired any medical expertise as to these disorders which are medically complex. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). Accordingly, the lay evidence does not constitute competent medical evidence and lacks probative value. In conclusion, the Board finds that service connection for a bilateral leg condition, to include peripheral vascular insufficiency and peripheral neuropathy, is not warranted. When all the evidence is assembled, VA is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). The preponderance of the evidence is against the claim. Jennifer White Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mohammad Mahmoudi, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.