Citation Nr: 21067619 Decision Date: 11/04/21 Archive Date: 11/04/21 DOCKET NO. 19-38 842 DATE: November 4, 2021 ORDER Entitlement to service connection for bilateral lower extremity peripheral vascular disease is granted. FINDINGS OF FACT The competent and credible evidence of record is in equipoise as to whether bilateral lower extremity peripheral vascular disease is the result of service. CONCLUSIONS OF LAW The criteria for entitlement to service connection for bilateral lower extremity peripheral vascular disease have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1953 through July 1955. In April 2021, the Board remanded this case for additional development. The Board finds that there has been substantial compliance with the remand requests. Stegall v. West, 11 Vet. App. 268 (1998). The Board notes that the service personnel and service medical records are incomplete. The record shows that the National Personnel Records Center indicated that the Veteran's service personnel and medical records were fire-related and were lost in a fire at a storage facility. In cases where records once in the hands of the government are lost, the Board has a heightened obligation to explain its findings and conclusions and to resolving reasonable doubt in favor of the claimant, where applicable. O'Hare v. Derwinski, 1 Vet. App. 365 (1991). Because of missing records, the analysis below has been undertaken with the heightened duty in mind. The case law does not lower the legal standard for proving a claim for service connection but rather increases the Board's obligation to evaluate and discuss in the decision all of the evidence that may be favorable to the claimant. Russo v. Brown, 9 Vet. App. 46 (1996). Service Connection Service connection may be established for disability caused by disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. In order to establish service connection for a claimed disability, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence, generally medical, of a causal relationship between the claimed in service disease or injury and the current disability. Hickson v. West, 12 Vet. App. 247 (1999). Service connection may also be established for any disease initially diagnosed after service, when the evidence establishes that the disease was incurred in service. 38 U.S.C. § 1113(b); 38 C.F.R. § 3.303(d); Cosman v. Principi, 3 Vet. App. 503 (1992). The disease entity for which service connection is sought must be chronic rather than acute and transitory in nature. For the showing of chronic disease in service, a combination of manifestations must exist sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word chronic. Service incurrence will be presumed for certain chronic diseases if manifest to a compensable degree within the year after active service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309. The Veteran is competent to report symptoms and experiences observable by his senses. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a). Lay evidence presented by a Veteran concerning continuity of symptoms after service may generally be considered credible and ultimately competent, regardless of a lack of contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (2006). Entitlement to service connection for bilateral lower extremity peripheral vascular disease The Veteran asserts that bilateral lower extremity peripheral vascular disease is the result of service. Specifically, the Veteran asserts that while in Korea, he sustained a cold injury to the lower legs and feet. In a June 2018 statement, the Veteran stated that many times he thought he had frostbite because it was so hard to feel his legs and feet. He stated that after separation from service, his feet were always cold, and his wife had to rub his legs and feet with warm towels. During a February 2021 Board hearing, the Veteran and his witnesses testified that while in Korea, the Veteran worked outdoors in cold and rainy weather; his feet were cold, painful, and numb while in service; and his feet were cold, painful, and had poor circulation after separation from service. A July 1955 separation examination shows that the feet and lower extremities were normal. A cardiolipin antibody test was performed. The results of the cardiolipin antibody test were negative. A July 2021 VA examination diagnosed bilateral lower extremity peripheral vascular disease. The examiner opined that bilateral lower extremity peripheral vascular disease was not the result of service. The examiner stated that the Veteran's reports of cold lower extremities while in Korea were physiological normal. However, the bilateral lower extremity symptoms that persisted after separation from service were unrelated to service. The examiner noted that frost bite injury caused by cold weather resulted in damage to the skin and underlying tissue which in severe cases could lead to infection and nerve damage. The examiner stated that bilateral lower extremity peripheral vascular disease was developed as a result of the Veteran's long history of cigarette smoking and elevated levels of cholesterol or hyperlipidemia. The examiner stated that "[s]ince the Veteran started smoking at least 5 years prior to active service, there would [have been] some degree of arteriosclerosis that had already developed which explains why even after returning to warmer environments [the Veteran's] feet continued to feel cold to the touch. There [wa]s no current or previous evidence that the Veteran sustained frost bite to his bilateral lower extremities during his exposure to extremely cold weather while deployed to Korea during winter and his current symptoms c[ould] be explained by peripheral vascular disease related to a history of tobacco smoking and Hyperlipidemia." The Board is not free to substitute its own judgment for that of a medical expert. Colvin v. Derwinski, 1 Vet. App. 171 (1991). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. Equal weight is not given to each piece of evidence contained in the record. Every item of evidence does not have the same probative value. When the evidence is assembled, the Board is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The July 2021 VA examiner did not discuss the July 1955 cardiolipin antibody test. However, a cursory internet search shows that cardiolipin antibody tests are performed when individuals have symptoms which suggest unexplained blood clots. Uptodate.com states that cardiolipin is a phospholipid and that individuals with antiphospholipid antibodies may have antiphospholipid syndrome (APS). Physical manifestations of APS may show "findings consistent with livedo reticularis (and particularly livedo racemosa)..." Livedo reticularis and livedo racemosa present as a localized or widespread, patchy, red-blue or violet, vascular patterns. Livedo reticularis and livedo racemosa may also be a symptom of cutaneous vasculitis which most commonly occurs in a symmetrical distribution on the lower legs and may be associated with pain, itching, or burning sensations. In offering the July 2021 opinion, the examiner did not consider other possible pathology such as a nonfreezing cold injury (NFCI) or trench foot. The Board notes that uptodate.com states that NFCI is an injury to the soft tissues, nerves, and vasculature of distal extremities due to prolonged exposure to cold and wet conditions. NFCI impairs circulation and damages microcirculation. Some studies suggest that there can be "permanent damage to nerves from cold, as well as damage to the microvascular blood supply of the nerves." A known risk factor for NFCI is wearing combat boots. "Underlying circulatory problems may contribute to the risk or severity of NFCI...Smoking, older age, and ethnicity may play a role, but data are lacking." Extremities with NFCI go through several stages which vary in duration. "The fourth and final stage may end after a few weeks, persist for years, or be permanent." In the fourth stage, the affected extremity appears normal, it is cool, very sensitive to cold, and experiences vasoconstriction in response to cold. Prolonged episodes of vasoconstriction and pain can occur after re-exposure to cold. Severe sequelae and chronic pain may result. The Board finds that resolving reasonable doubt in favor of the Veteran, the evidence is in relative equipoise as to whether the Veteran had signs and symptoms of NFCI while in service and after separation from service. The evidence indicates that the Veteran more than likely had some lower extremity symptomatology at separation from service and he has competently and credibly testified as to the continuity of symptomatology since service. The Veteran is competent to report observable symptoms. Layno v. Brown, 6 Vet. App. 465 (1994). The Board finds the Veteran's reports credible. The Veteran reported exposure to cold and wet weather during two winters in Korea. The Veteran reported bilateral lower extremity symptoms, which were consistent with NFCI, following cold exposure. Specifically, the Veteran stated that the lower extremities were cold, painful, and had poor circulation. The Veteran reported that symptoms began in service and continued after separation from service. The VA examiner opined that arteriosclerosis was present when the Veteran entered service, and uptodate.com states that circulatory problems may contribute to the risk and severity of NFCI. Moreover, the Board places great probative value on the Veteran's reports and the partially complete medical record. Namely, considering the Veteran's reports of poor circulation after returning from Korea and the cardiolipin testing performed in July 1955, the Board finds that there is plausible basis to conclude that the Veteran had symptoms of circulation problems of the lower extremities while in service. Further, the Board finds that the Veteran's reports lower leg symptoms following exposure to cold and wet conditions coupled with the negative cardiolipin test results, provide a plausible basis to conclude that lower extremity circulation problems were likely the result NFCI due to repeated exposure to cold and wet weather conditions while in service. Therefore, the Board finds that bilateral lower extremity symptoms began while in service and continued after separation from service. Accordingly, resolving reasonable doubt in favor of the Veteran, the Board finds that service connection for bilateral lower extremity peripheral vascular disease is warranted. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Harvey P. Roberts Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E.O., 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.