Citation Nr: 21062319
Decision Date: 10/07/21	Archive Date: 10/07/21

DOCKET NO. 15-33 724
DATE: October 7, 2021

ORDER

Service connection for residuals of left calf numbness associated with chronic left lower back radiating pain syndrome is granted.

FINDING OF FACT

The evidence reasonably shows that the Veteran's residuals of left calf numbness associated with chronic left lower back radiating pain syndrome is secondary to his service-connected back disability.

CONCLUSION OF LAW

The criteria for residuals of left calf numbness associated with chronic left lower back radiating pain syndrome secondary to his service-connected back disability. have been met. 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 November 1979 to April 2001. Concerning the issue at hand, the matter comes to the Board of Veterans' Appeals (Board) from a January 2012, rating decision by a Regional Office (RO) of the United States Department of Veterans Affairs (VA) that denied service connection for his left calf disability. In terms of the Veteran's back strain, he is service connected as of July 2021.

In pertinent part, in March 2019, the Board issued a decision which denied service connection for a right ankle strain and left calf disability. In March 2020, the Veteran appealed the case to The Court of Appeals for Veterans Claims (CAVC or the Court). In September 2020, the Court granted a Joint Motion for a Partial Remand, vacating the prior denial, and remanding for corrective action. 

In March 2021, the Board remanded the case. to get VA examinations and opinions addressing the nature and etiology of the Veteran's claimed right ankle and left calf disabilities. 

In May 2021, the Veteran was granted service connection for his right ankle disability.

Duties to notify and assist

In March 2020, the Veteran, through his representative, appealed the March 2019 Board decision, before the Court. In that appeal, the Veteran claimed that the VA failed in its duty to assist. In September 2020, the Court remanded the denied issues for action consistent with a Joint Motion. In March 2021 following the Court's remand, the Board again remanded the case to get VA examinations and opinions regarding the nature and etiology of the Veteran's claimed right ankle and left calf disabilities. Following the Board's March 2021 remand, the Veteran was granted service connection for his right ankle disability. In May 2021, however, he was denied service connection for his calf disability. In June 2021, the Veteran appealed the denial, claiming that the left calf disability should be service connected. 

As of June 2021, the Veteran has not raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings liberally does not require the Board...to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument).

Legal Criteria

Service connection may be granted for a disability resulting from disease or injury incurred or aggravated during active military service. 38 U.S.C. § 1110. Generally, service connection requires (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. § 3.303(d).¬¬

Establishing secondary service connection requires evidence: (1) of a current disability (for which secondary service connection is sought); (2) of a service-connected disability; and (3) that the current disability was either caused or aggravated by the service-connected disability. 38 C.F.R. § 3.310(a); see Allen v. Brown, 7 Vet. App. 439 (1995).

Where a Veteran must obtain a medical option as part of his attempt to service connect a disability, the examination must be adequate. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (quoting Ardison v. Brown, 6 Vet. App. 405, 407 (1994)) (A VA medical opinion is adequate if it is "thorough and contemporaneous," considers the veteran's prior medical examinations and treatment, and "describes the disability. in sufficient detail so that the Board's 'evaluation of the claimed disability will be a fully informed one.'"); see Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) ("[A] medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two" and "most of the probative value of a medical opinion comes from its reasoning.").

Factual Background

In March 2021, the Board remanded the claim to provide the Veteran a new examination and medical opinion. The April 2021 examination explicitly diagnosed the Veteran with left calf numbness associated with chronic left lower back radiating pain syndrome. The examiner made a separate and clearly distinct diagnosis from the Veteran's already service-connected "radiculopathy, left lower extremity (claimed as left foot condition manifested by numbness and pain)." 

Analysis

The evidence of record indicates that the Veteran has a left calf condition. What remains for consideration is whether the Veteran's left calf disability is causally related to his service-connected low back disability. During the Veteran's April 2021 direct service connection examination for his left calf disability, the examiner stated that the Veteran's left calf disability was less likely than not incurred in, or caused by, a claimed in-service injury or event. The examiner instead opined that the Veteran's left calf disability was associated with radiating back pain from his left lower back. At the time that the examiner wrote his opinion, the Veteran had not yet been service connected for a low back condition. In July 2021, the Veteran was granted service connection for his low back condition. Because the April 2021 examination associated the Veteran's now service-connected low back condition to his calf condition, the Veteran may now obtain secondary service connection for his left calf disability. The April 2021 examination associated the Veteran's low back condition with his left calf condition. Moreover, the April 2021 examination considered the Veteran's past medical history reviewed his C-file and provided a rationale. It is therefore adequate. see Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008).

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Accordingly, the Board finds that resolving reasonable doubt in favor of the Veteran, that the Veteran's diagnosed residuals of left calf numbness associated with chronic left lower back radiating pain syndrome is secondary to his service-connected back disability.

 

David Gratz

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Mintz, Allison

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.