Citation Nr: 21065699 Decision Date: 10/27/21 Archive Date: 10/27/21 DOCKET NO. 14-13 009 DATE: October 27, 2021 ORDER Service connection for venous insufficiency of the right lower extremity is denied. Service connection for venous insufficiency of the left lower extremity is denied. FINDING OF FACT The Veteran's venous insufficiency of the bilateral lower extremities did not have its onset during service and is not otherwise related. CONCLUSIONS OF LAW 1. The criteria for service connection for venous insufficiency of the right lower extremity have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for venous insufficiency of the left lower extremity have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSIONS The Veteran served on active duty from August 1988 to June 1990 and from January 1991 to March 1991. The case is on appeal from a January 2010 rating decision. In August 2015, the Veteran testified at a Board hearing. In September 2019, the Board denied the claims. The Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (Court). Pursuant to a September 2020 Joint Motion for Remand (JMR), the Court vacated the Board's September 2019 decision by a September 2020 Order and remanded the case to the Board. The claims were most recently remanded by the Board in March 2021 for further development. A left knee disorder claim was also remanded. While in remand status, in a May 2021 rating decision, the RO granted the claim. Thus, that issue is no longer on appeal. Additional evidence was received following the most recent June 2021 supplemental statement of the case (SSOC). However, this additional evidence is not relevant to the issues decided herein. Therefore, remand for initial RO consideration is not necessary. See 38 C.F.R. § 20.1305(c). The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. A veteran seeking compensation under these provisions must establish three elements: "(1) the existence of a present disability; (2) 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." Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). 1. Service connection for venous insufficiency of the right lower extremity. 2. Service connection for venous insufficiency of the left lower extremity. Facts The Veteran contends that his venous insufficiency of the bilateral lower extremities is related to service, to include his in-service use of Accutane. The Veteran's service treatment records (STRs) are silent for treatment or diagnosis of venous insufficiency of the lower extremities. However, the STRs confirm the required use of Accutane to treat skin problems the Veteran experienced. The Board notes VA treatment records show the Veteran sought treatment for venous insufficiency of his lower extremities as early as May 2004. A VA treatment record from June 2005 indicated the Veteran has chronic insufficiency with recurring stasis ulcer in the left leg. Following the Veteran's August 2009 claim, he submitted a March 2010 statement in which he asserts his use of Accutane caused problems with his cardiovascular system and led to his diagnosed lower extremity venous insufficiency. The Veteran was afforded a November 2011 VA examination in which the examiner opined his venous insufficiency was less likely than not incurred in or caused by service. She indicated after a review of the medical literature the Veteran's disorders are not related to previous Accutane use. The Veteran testified during the August 2015 Board hearing that his in-service use of Accutane led to his lower extremity venous insufficiency. He stated the Accutane caused a lot of side effects which may have led to his lower extremity venous insufficiency. The claim came before the Board in November 2015 and was remanded for further development, including a VA examination. The Veteran was afforded a February 2016 VA examination in which he was diagnosed with vascular insufficiency. The Veteran reported vascular insufficiency for over eight years, beginning after service. Additionally, he submitted a medical article suggesting a link between his lower extremity disorders and Accutane use. His reported symptoms include feeling "needles" in his feet and legs. The examiner opined the lower extremity disorder was not related to service, including the use of Accutane. He indicated the Veteran's use of Accutane during service was for a short period of time and he had no signs of vascular insufficiency during service or related to in-service activity or medication. The claim came before the Board in February 2019 and it determined the claims should be remanded for further development, including an additional VA examination with a discussion of the side effects of Accutane. The Veteran was afforded an April 2019 VA examination in which the examiner determined the Veteran's lower extremity venous insufficiency was not related to service. She indicated the Veteran's STRs do not contain any indication that he had problems with varicose veins or venous insufficiency during service. She reported an examination performed in January 1991, near the end of the Veteran's service, did not discuss any issues related to varicose veins or venous insufficiency and he first sought medical care for venous insufficiency in May 2004. The April 2019 examiner noted the Veteran was on Accutane for his acne for three months in 1990, as indicated in dermatology records from April and May 1990. The examiner stated the side effects of Accutane do not include the development of venous insufficiency or varicose veins and thus, the Veteran's bilateral lower extremity venous insufficiency was less likely than not incurred in or caused by service, including his use of Accutane. The Board denied the claim in the September 2019 decision and as noted, the Veteran appealed the decision to the Court. In the September 2020 JMR, the parties agreed the April 2019 VA examination report was inadequate, as the examiner did not thoroughly address the lay evidence of record or medical literature regarding the side effects of Accutane. Following issuance of the September 2020 JMR, the Board remanded the claims in March 2021 for further development pursuant to the Court remand. The Veteran was afforded a May 2021 VA examination in which the examiner indicated his lower extremity venous insufficiency is not related to service, to include his Accutane use, and a nexus has not been established. She opined after review of the record, as well as the relevant medical literature, there is no evidence which supports that Accutane use can lead to venous insufficiency. The examiner noted there are many side effects of Accutane, including bone or joint pain, burning, redness, itching, bruising, inflammation, difficulty moving the arms and legs, and swelling of the lower legs or feet. However, she indicated the medical literature supports that there is no incidence of side effects which cause numbness, prickling, "pins and needles", or tingling in the extremities. The May 2021 examiner noted the Veteran's reports of experiencing red patches and bruises on his legs during service and while he was using Accutane. She further indicated the side effects of Accutane include increased bruising and causing redness to the skin. However, she stated the redness to the Veteran's skin is most likely related to increased sun sensitivity after his use of Accutane. She noted the Veteran was only taking Accutane for 3 to 4 months and if red patches and bruising did occur, it was a temporary condition. She stated when the medication was stopped after 3 or 4 months, the condition would have resolved. The examiner opined after a thorough review of the literature related to Accutane, it is her medical opinion that the Veteran's in-service use of Accutane did not cause his venous insufficiency. Analysis After a careful review of the medical and lay evidence of record, as well as the medical literature related to Accutane, the Board determines service connection for bilateral lower extremity venous insufficiency is not warranted. The most persuasive medical evidence of record supports that the Veteran's lower extremity conditions are not causally related to service, to include the use of Accutane. In reaching this conclusion, the Board accords great probative weight to the May 2021 VA examination report. Following the September 2020 JMR, as well as the March 2021 Board remand, the Veteran was afforded a May 2021 VA examination and opinion. The Board finds this opinion is thorough and adequate with regard to the etiology of the Veteran's bilateral lower extremity venous insufficiency disorders. Such opinion discussed the evidence of record, including the Veteran's in-service use of Accutane. She further addressed the Veteran's lay contentions and the medical literature of record, with discussion related to the side effects of Accutane. The examiner's opinion is consistent with the evidence of record and addresses whether the Veteran's lower extremity disorders are etiologically related to his prior Accutane use. The examiner adequately reviewed and discussed the medical evidence of record, as well as relevant medical literature. Moreover, the opinion contains clear conclusions with well-reasoned explanations in support. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board notes there are no medical opinions of record which support a causal link between the Veteran's in-service use of Accutane and his diagnosed bilateral lower extremity venous insufficiency. The Board acknowledges the Veteran's consistent lay contentions, including that his current lower extremity venous insufficiency is causally related to service. Further, the Board acknowledges the Veteran's in-service Accutane use. However, while the Veteran as a lay person is competent to report the lower extremity symptoms he experienced during service, he lacks the requisite expertise to render a medical opinion as to the etiology of his bilateral lower extremity venous insufficiency. This is a complex medical question which falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1977 (Fed. Cir. 2007). Therefore, the Veteran's lay statements as to the etiology of his lower extremity venous insufficiency are afforded less probative weight than the May 2021 VA examination report. In sum, the Board determines the Veteran's bilateral lower extremity venous insufficiency is not related to service, including the use of Accutane. The preponderance of the evidence is against the claims and the benefit of the doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Therefore, service connection for bilateral lower extremity venous insufficiency is not warranted. RYAN T. KESSEL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Isaacs, Brandon 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.