Citation Nr: 21066552 Decision Date: 11/01/21 Archive Date: 11/01/21 DOCKET NO. 14-15 310 DATE: November 1, 2021 ORDER Entitlement to service connection for ischemic heart disease (IHD) is denied. Entitlement to service connection for hypertension is denied. Entitlement to service connection for erectile dysfunction, to include as secondary to posttraumatic stress disorder (PTSD), is granted. Entitlement to service connection for low back arthritis is granted. Entitlement to service connection for right lower extremity sciatica, to include as secondary to service-connected disabilities, is granted. Entitlement to service connection for left lower extremity sciatica, to include as secondary to service-connected disabilities, is granted. FINDINGS OF FACT 1. There is no competent evidence of record showing the Veteran has heart disease that was incurred in or otherwise caused by his service. 2. There is no competent evidence of record showing the Veteran has hypertension that was diagnosed within one year of separating from or was due to his service, to include exposure to herbicides and/or secondary to a service connected disability. 3. A preponderance of the competent evidence shows that the Veteran's erectile dysfunction was caused or aggravated by the medication used to treat his psychiatric condition. 4. Resolving reasonable doubt in favor of the Veteran, the evidence of record shows that his lumbar spine disability was caused or aggravated by his left knee disability. 5. Resolving reasonable doubt in favor of the Veteran, the evidence of record shows that his bilateral lower extremity sciatica was caused or aggravated by his left knee disability. CONCLUSIONS OF LAW 1. The criteria for service connection for heart disease have not been met. 38 U.S.C. §§ 1110, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 2. The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1110, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 3. The criteria for service connection for erectile dysfunction, to include as secondary to PTSD, have been met. 38 U.S.C. §§ 1110, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 4. The criteria for service connection for low back arthritis have been met. 38 U.S.C. §§ 1110, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 5. The criteria for service connection for right lower extremity sciatica, to include as secondary to service-connected disabilities, have been met. 38 U.S.C. §§ 1110, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 6. The criteria for service connection for left lower extremity sciatica, to include as secondary to service-connected disabilities, have been met. 38 U.S.C. §§ 1110, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the U.S. Marine Corps from July 1963 to October 1967. The Board remanded the appeal in February 2018 requesting the AOJ obtain additional records pertaining to the Veteran's heart disease claim, opinions regarding lumbar spine, bilateral sciatic and erectile dysfunction, and schedule him for a VA heart examination. AOJ obtained the treatment records and scheduled him for VA examinations. The AOJ was unable to obtain opinions. The Veteran cancelled the examinations and neither, he nor his representative, provided an explanation. The Board remanded the appeal once more in May 2020, again requesting the Veteran be scheduled for a VA examination, and obtain addendum opinions for his spine, sciatica, and erectile dysfunction. While on remand, the AOJ scheduled the Veteran for VA examinations. In June 2021, the AOJ contacted the Veteran and asked if he would be willing to report for VA examinations. He indicated that he did not wish to attend any examination and would prefer that his claims be evaluated based on the evidence of record. In August 2021, the Veteran's representative argued that the Veteran had not been informed of the scheduled examinations and should be afforded another opportunity. The Board finds that VA has provided multiple opportunities to appear for VA examinations to determine the nature and etiology of his claimed disabilities. Such examinations could provide beneficial evidence to support his claims. Nevertheless, he declined to attend such examinations. Despite the August 2021 argument from the Veteran's representative requesting another opportunity, the Board finds that any further attempts to schedule VA examinations would be futile as the Veteran specifically indicated his wish to have a decision made based on the evidence of record. VA has met its duty to assist. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). The law also provides a disability may be service connected on a secondary basis by demonstrating that the disability is either (1) proximately due to or the result of an already service-connected disease or injury or (2) aggravated by an already service-connected disease or injury. See Allen v. Brown, 7 Vet. App. 439, 448 (1995); 38 C.F.R. § 3.310. Certain chronic diseases will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). In November 2018, the National Academy of Sciences (NAS) reclassified hypertension to the category of "sufficient evidence" of an association from its previous classification in the "limited or suggestive evidence" category. The sufficient category indicates that there is enough epidemiologic evidence to conclude that there is a positive association between hypertension and exposure to Agent Orange. See Veterans and Agent Orange: Update 2018. However, hypertension is still not included as a presumptive disability for which service connection may be granted under 38 C.F.R. § 3.309(e). Notwithstanding the presumption, however, service connection for a disability claimed as due to exposure to herbicides may be established by showing that a disorder resulting in disability or death was in fact causally linked to such exposure. See Combee v. Brown, 34 F.3d 1039, 1044 (Fed. Cir. 1994)(citing 38 U.S.C. § 1113(b) and 1116 and 38 C.F.R. § 3.303). 1. Entitlement to service connection for heart disease. As noted above, the first element of service connection is a current disability. Although the Veteran has been presumed to have been exposed to herbicides in service, the Board finds that he does not have a current diagnosis of any heart disease for which service connection can be awarded. Service treatment records are silent for any complaints, treatment, or diagnosis of any heart condition. His October 1967 separation exam indicated his heart was normal. A stress test was conducted at a private facility in December 1995 following his reports of panic attacks accompanied by chest pain and shortness of breath. Test results were normal. A pre-exercise EKG showed a right bundle branch block but was otherwise it was within normal limits. VA treatment records show a heart attack that damaged the lower part of the heart in 1999, a history of coronary artery disease status post myocardial infarction with 2001 cardiac catheterization. Another 2002 record shows mitral regurgitation and a chest x-ray report with the note "There is arteriosclerotic heart disease." A problem list from a September 2019 treatment record shows "transient ischemic attack" in May 2007 and coronary arteriosclerosis, status post myocardial infarction in October 2006. There was also a note that the Veteran experience ischemic episodes since myocardial infarction in 1998. Other private treatment records also show a history of mitral regurgitation (from a record dated June 2003), coronary artery disease and myocardial infarction (from record dated March 2011.) However, other records contradict these findings. The May 2001 catherization was negative for disease and showed normal coronary arteries with mild tardive kinesis of the anterior wall. A July 2010 chest x-ray did not identify any acute cardiopulmonary process. An echocardiogram completed in March 2011 demonstrated right bundle branch block (which was unchanged from prior testing) but normal sinus rhythm. The Veteran reported a vague history of a heart attack and intermittent chest discomfort that was occasionally alleviated by antacids. The examiner noted that the atypical chest pain may be related to esophageal disease in a patient with reported coronary artery disease. An April 2011 stress test was normal and did not show any evidence of prior heart attack. The Veteran was afforded a VA examination in August 2011 and reported that he was told he had a heart attack in the past. He underwent a cardiac catheter in in 2001 which showed a heart attack. The examiner noted that requested records indicated normal coronary arteries with tardive kinesis of the anterior wall. "Well maintained global ejection fraction and normal hemodynamics." A nuclear perfusion study was conducted in April 2011 and was normal. There was no evidence of prior myocardial infarction or ischemia, and normal ejection fraction with no evidence of wall motion abnormalities. Ultimately, the examiner found that a diagnosis of heart disease was not found. The Veteran has reported chest pain which has been associated with a diagnosis of Barret's esophagus. The AOJ requested an opinion from a VA clinician to clarify whether the Veteran has a current diagnosis of heart disease. The contractor confirmed that an opinion could not be provided without a full examination. The Veteran indicated that he did not wish to report for an exam, as such the opinion was not completed. The Board notes that the opinion would have had a significant impact on this decision. The available evidence of record does not show a current diagnosis of heart disease that was caused by or otherwise related to his service. Although there is some evidence in support of his claim, these records were largely based on his own lay reports following what he believed he was told or read. Specifically, the Veteran believed the 2001 catherization showed heart disease and consistently reported that over the years. However, the actual record of the 2001 catherization was negative for any disease. Other testing completed in 2010 and 2011 did not show any evidence of prior myocardial infarction or ischemia. The Board acknowledges the Veteran's lay statements and sincere belief that he has heart disease that is related to service, specifically his exposure to herbicide agents. Although he is competent to state symptoms he experiences, he is not competent to provide a diagnosis. He has not demonstrated that he has the necessary medical expertise to provide such an opinion. Therefore, his opinions on the matter lack probative weight. Instead, the Board affords more probative weight to the medical evidence of record, to include the August 2011 VA examination, which were provided by competent medical clinicians. Without competent evidence showing a current diagnosis of heart disease, the first element of service connection has not been met. As such, service connection for a heart condition is not warranted. 2. Entitlement to service connection for hypertension. Private treatment record indicates hypertension was diagnosed in May 2001, as such the first element of service connection has been met. The Veteran is not service connection for heart disease, as such the second element of secondary service connection is not met. Service connection on a secondary basis is not warranted. Service treatment records are negative for complaints, treatment, or diagnosis. His exit examination indicated a blood pressure reading of 124/86. See VA Clinician's Guide, Chapter 7, 7.12 (June 2002) (indicating that systolic pressure less than 130 and diastolic pressure less than 85 is considered normal and stage I hypertension is classified as 140 to 159 systolic or 90 to 99 diastolic). Irrespective of inservice complaints, the Veteran has been presumed to have been exposed to herbicides. Therefore, the second element of direct service connection has been met. As noted above, on discharge, the Veteran's blood pressure was noted to be 124/86, which is considered a normal blood pressure reading. He did not have any in-service readings indicating elevated blood pressure, much less a diagnosis of high blood pressure or hypertension. The earliest VA examination report of record dated in January 1968 does not indicate the Veteran had a diagnosis hypertension. In addition, when filing his original claim after discharge from service, the Veteran did not report any symptoms of elevated blood pressure or a history of hypertension. The earliest diagnosis of hypertension is contained in a private treatment record dated in May 2001. At that time, the Veteran's blood pressure reading was 118/72. The earliest indication of an elevated reading is in October 1972 and it was read at 140/86. Other private treatment records from July 1976, March 1994, April 1994 indicate blood pressure readings of 112/80, 110/70 and 140/78, which are considered normal. Also, in April 1994, the Veteran's fiancé measured his blood pressure and it ranged from 150/100 to 170/110, but when he went to the emergency room later on, it was measured as normal. In any event, these elevated readings and diagnosis were documented approximately 34 years post-service. Thus, the Board finds that the evidence weighs against finding that the Veteran's hypertension had its onset within one year of service. Therefore, service connection on a presumptive basis is not warranted. As detailed above, the Veteran failed to attend a VA examination to determine the etiology of his hypertension. As such, there is no VA opinion of record addressing whether the Veteran's hypertension was caused or aggravated exposure to herbicides. Although the NAS Update indicates a possible relationship, an examiner would have to provide opinion with clear conclusions and a supporting rationale addressing the facts relevant to the Veteran's appeal. Such has not been accomplished. The Board acknowledges the Veteran's lay statements and sincere belief that his hypertension is related to service, specifically his exposure to herbicide agents, or his service-connected disabilities. Although he is competent to state symptoms he experiences, he is not competent to provide an opinion as to the etiology of his hypertension. He has not demonstrated that he has the necessary medical expertise to provide such an opinion. Therefore, his opinions on the matter lack probative weight. Instead, the Board affords more probative weight to the medical evidence of record, to include his service treatment records, which were provided by competent medical clinicians. As noted above, there are no medical opinions of record in support of the Veteran's claim for service connection for hypertension. The preponderance of the evidence weighs against the Veteran's claims. In such case, the benefit-of-the-doubt doctrine is not for application and the claims for service connection for hypertension must be denied. 3. Entitlement to service connection for erectile dysfunction, to include as secondary to PTSD. The Veteran contends that he has erectile dysfunction as secondary to medication he was prescribed for other service connected disabilities. Alternatively, he contends that it was related to his psychiatric diagnosis. The March 2015 VA examination show the Veteran has a current disability of erectile dysfunction. Treatment records confirm an onset of approximately February 2010. The examiner opined that it was less likely as not that the Veteran's erectile dysfunction was proximately due to or the result of medication taken for his PTSD. Specifically, the examiner noted that the Veteran's erectile dysfunction did not occur until 2010 when lab results showed low testosterone and all of his prescriptions predated this diagnosis by 3 to 8 years. A letter from a private physician received in May 2014 indicated that Veteran's erectile dysfunction was exacerbated by chronic stress and PTSD. The Board finds that March 2015 opinion to be of little probative value because the examiner based the negative conclusion on prescriptions predating the diagnosis of erectile dysfunction. The Veteran contends the use of these medications caused his dysfunction, which implies that the use occurred before the onset of the claimed condition. Moreover, the examiner failed to address aggravation. Therefore, the March 2015 opinion is incompetent and inadequate. The Board finds the private examiner's opinion, when looked at in conjunction with the Veteran's lay statements, to be of more probative value. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran's current erectile dysfunction is proximately due to his service-connected PTSD and/or the medication used to treat his psychiatric symptoms. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for erectile dysfunction is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 4. Entitlement to service connection for a low back disability. 5. Entitlement to service connection for right lower extremity sciatica, to include as secondary to service connected disabilities. 6. Entitlement to service connection for left lower extremity sciatica, to include as secondary to service connected disabilities. Per the August 2011 VA examination, the Veteran has a diagnosis of mild osteoarthritis in his lumbar spine. In a 2010 treatment summary, the Veteran's chiropractor confirmed a diagnosis of sciatica related to his lumbar spine condition. As such, the first element of service connection has been met for both issues. Service treatment records show two notes of back pain. The first was following a fall during physical training in September 1963. He reported lower back pain that lasted several weeks. A February 1966 note indicated back pain related to a possible flu-like illness. However, his October 1967 separation examination showed a normal spine. The Veteran reported that he began shifting weight to his right side following surgery on his left knee. He experienced painful motion and weakness. October 2009 private treatment records show the Veteran reported numbness and occasional pain in his left leg, that radiated up to the thigh and buttocks. The treatment note indicated that these symptoms were associated with left knee disability. At that time, the Veteran denied any injury to his back. The August 2011 VA examiner found that his lumbar spine disability was less likely than not related to his service or secondary to his service-connected left knee disability. The examiner reviewed various treatment records including a July 2010 note showing the Veteran was seen for lower back pain that was had a spontaneous onset approximately three days prior. In a February 2012 letter, a private chiropractor noted that he first began treating the Veteran for low back spasms and right hip and leg pain in October 2009. The primary diagnosis was acute subluxation/fixation of the right sacroiliac joint with associated spasm of the paraspinal musculature, complicated by nerve root compression at L4-L5 and sciatica down the right leg. The examiner opined that the onset of sciatica occurred after his left knee surgery. Due to the Veteran favoring his left knee/leg after surgery and altering his gait while recuperating, he developed right hip, low back pain, and eventually compromised the sciatic nerve. In April 2014, a private examiner submitted a letter summarizing the Veteran's orthopedic conditions. Specifically, the examiner found that his recovery for his left knee was inhibited by a severe episode of sciatica, which was quite disabling. In April 2014, the private chiropractor noted that he developed chronic lower back pain in approximately 2010. He complained of left lower back spasms and pain radiating down his left leg since his left knee replacement surgery in 2010. The condition worsened after his right knee was replaced in 2012. The examiner found that the Veteran's lumbar spine had to compensate for multiple knee surgeries, which has led to chronic nerve root irritation at L4-L5. This condition is complicated by sciatica down his left leg. The Veteran was afforded another VA examination in March 2015 and reported carrying 100+ pound loads while serving in Vietnam that caused severe pain in his back. The examiner confirmed a diagnosis of degenerative disc disease but ultimately found that it was less likely than not proximately due to or the result of his service-connected left knee disability. Specifically, the evidence did not show severe gait abnormalities and his legs are the same length. X-rays showed mild osteoarthritis with preserved disc spaces, so nerve impingement causing radiculopathy originating from the spine is unlikely as is "sciatic" pain ascending from the knee. The Veteran has been unable to tolerate EMG testing for sciatica in the past. The examiner opined that mild osteoarthritis is a common finding in 70-year-old individuals after decades of a generally active lifestyle. In conclusion, the examiner fund that pain of the lower limb is not a recognized cause of spinal conditions. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran's current lumbar spine disability and lower extremity sciatic are proximately due to his service-connected left knee disability. Private treatment records show the Veteran's lumbar spine disability and associated sciatica were likely caused by carrying weight on his right side and/or favoring his left knee/leg after surgical intervention. Both the August 2011 and March 2015 VA examiners provided negative opinions indicating that a knee disability would not cause a low back disability and the evidence did not show any gait abnormalities. The Board finds both opinions to be of little probative value because the examiners failed to address aggravation component of secondary service connection. Therefore, both opinions are inadequate. The Board finds the private examiners' treatment records, when looked at in conjunction with the Veteran's lay statements, to be of more probative value. (Continued on the next page) Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for a lumbar spine disability, and bilateral lower extremity sciatica is warranted on a secondary basis. H.M. WALKER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Price, Esq. 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.