Citation Nr: 21073747 Decision Date: 12/10/21 Archive Date: 12/10/21 DOCKET NO. 18-26 689 DATE: December 10, 2021 ORDER 1. Entitlement to service connection for May-Thurner Syndrome (MTS) of the left lower extremity, including the left ankle, is denied. 2. Entitlement to service connection for tinnitus is granted. 3. Entitlement to service connection for gastroesophageal reflux disease (GERD) is granted. FINDINGS OF FACT 1. MTS of the left lower extremity did not have its onset during active service and is not otherwise related to active service. 2. Resolving reasonable doubt in favor of the Veteran, tinnitus had its onset during active service and has continued to manifest as recurrent tinnitus to a compensable degree. 3. Resolving reasonable doubt in favor of the Veteran, his post-service complaints of GERD are related to his complaints of GERD documented during active service. CONCLUSIONS OF LAW 1. The criteria for service connection for MTS of the left lower extremity, including the left ankle, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for tinnitus have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. The criteria for service connection for GERD have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Air Force from September 1996 to September 2000, from March 2005 to June 2005, and from July 2008 to May 2010. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. To establish a right to compensation for a present disability, a Veteran must show: (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. For certain chronic disorders, including tinnitus, service connection may be granted on a presumptive basis if the disease is manifested to a compensable degree within one year following service discharge. 1. Entitlement to service connection for MTS of the left lower extremity, including the left ankle. The Veteran claims that his MTS of the left lower extremity, including the left ankle, is related to his active service. At the May 2021 Board hearing, the Veteran testified that MTS was diagnosed in 2017, but that during his periods of active service, he experienced the symptomology associated with MTS, such as swelling in the left lower extremity and pain. Specifically, he reported three, separate instances involving severe swelling in the left ankle during active service, two in 2005 and one in 2009. He stated that in between 2009 and the 2017 diagnosis of MTS, he did not see a doctor for treatment but just dealt with his severe problems. His representative similarly asserted that medical records from the service period of 2005 to 2007 show that the Veteran was first suffering from MTS after a lower leg injury in 2005 and that the Veteran's report of severe edema and left lower leg swelling while deployed in Iraq from 2009 to 2010 is sufficient to establish a nexus to service. At the May 2021 Board hearing, the Veteran's representative provided a description of MTS. Specifically, the representative stated that it is "a condition in which the left iliac vein is compressed between the overlaying right iliac artery and the lumbar spine. It typically presents as left lower extremity edema and pain in the form of swelling and can be connected to activity that produces swelling and pressure in the vein." See Board Transcript on page 13. Following a review of the evidence of record, the Board finds that the preponderance of evidence weighs against the Veteran's claim for service connection for MTS of the left lower extremity, including the left ankle. The reasons for this decision follow. As to evidence of a current disability, private treatment records document that while he was overseas in Jordan (not during a period of active duty), the Veteran was hospitalized and treated for extensive deep vein thrombosis (DVT) and suspected MTS in his left lower extremity in early February 2017. Similarly, VA treatment records document that his condition was subsequently diagnosed as MTS. Therefore, the evidence establishes that the first element of a service-connection claim is met. Regarding the in-service element of the claim, the Board finds that service treatment records do not document complaints, treatment, or diagnosis of MTS during a period of active duty. While the Veteran does not contend MTS had its onset during the first period of active duty, the Board will still address what those records show. A December 2000 Report of Medical Assessment following his first period of active service documents that the Veteran denied receiving any related care or treatment, denied an injury or illness for which he did not seek medical care, reported no current conditions that limited his ability to work in primary military specialty, and denied any questions or concerns about his health. An August 2004 Report of Medical Examination completed in between the Veteran's first and second periods of active service documents that the Veteran had a normal clinical evaluation of the lower extremities. Additionally, the Veteran was given a PULHES score of 1 for each category during the August 2004 examination, showing he was found to have a high level of fitness in each category, which includes the lower extremities. See Odiorne v. Principi, 3 Vet. App. 456, 457 (1992). Similarly, an August 2004 Report of Medical History documents the Veteran's denial of any current or a history of foot trouble, impaired use of the legs or feet, swollen or painful joints, or a bone or joint deformity. The Veteran's main contention is that he had ankle symptoms during his second and third periods of active duty that he believes were misdiagnosed as an ankle disability versus MTS. During the Veteran's second period of active service, he was seen in April 2005 for follow up of ankle pain and was told that he had a bilateral stress fracture or stress changes and advised not to participate in physical readiness tests for the next three weeks. In November 2006, which was following his second period of active service and prior to his third period of active service, the Veteran reported that he was participating in takedown training the day before and suffered a left ankle injury. He reported increased pain and swelling and was referred for orthopedic consultation. Upon follow up in December 2006, diagnostic x-rays were negative, and the Veteran was assessed with a left ankle sprain. The Veteran completed a Post Deployment Health Assessment in February 2010 after his return from Iraq during which time he claims he was treated for severe swelling in his left ankle. Within this form, the Veteran was asked whether he went to see a healthcare provider, was placed on quarters, given light/limited duty, and whether he was still bothered by the symptom now. Below this question is a list of medical symptoms. The Veteran documented he was bothered by frequent indigestion/heartburn. One of the listed symptoms was swollen, stiff, or painful joints, and the Veteran did not document a positive history of that symptom. While he did not document a negative history of that symptom, it would seem that if he had experienced severe swelling as he had alleged, he would have documented that fact within this form, where he documented his indigestion/heartburn. When asked if he had been wounded, injured, assaulted or otherwise hurt during this deployment, he documented, "No." A March 2010 Report of Medical Assessment documents that the Veteran described his health as being the same compared to his last physical examination, and he denied any illnesses or injuries that caused him to miss duty for more than three days. He reported that since his last physical, he had been seen or treated for left shoulder pain and a dental ache, but stated that there were no other changes in his medical condition during this deployment. In other words, he did not report any specific left lower extremity problems including severe swelling. Similarly, he denied any other questions or concerns about his general health. These facts do not support the allegation of his experiencing "severe" swelling in his ankle that caused him to seek treatment for such symptom. Regardless, even if swelling in his ankle in 2009 is conceded, there is no competent evidence that this was indicative of MTS. Given the above, the Board finds that the probative evidence of record documents a complaint of ankle pain in April 2005 during the Veteran's second period of active service; however, service treatment records do not otherwise document that MTS had its onset during active service. The Board understands that the Veteran claims that the ankle pain he had during service was misdiagnosed and that the pain and swelling he experienced during a period of active service was indicative of MTS; however, there is no competent evidence to support this allegation. As stated by one of the representatives at the May 2021 hearing, MTS involves "a condition in which the left iliac vein is compressed between the overlaying right iliac artery and the lumbar spine. It typically presents as left lower extremity edema and pain in the form of swelling and can be connected to activity that produces swelling and pressure in the vein." See Board Transcript on page 13. The left iliac vein is in the area of the pelvis, which is at the top of the lower extremity. The Veteran specifically reported an injury to the ankle and was diagnosed contemporaneously with an ankle sprain. Thus, swelling in the ankle would be consistent with an ankle sprain. The Board finds that this was not a misdiagnosis of the ankle injury the Veteran sustained at that time. While the Veteran is competent to report swelling in his ankle, he is not competent to state that such swelling was indicative of MTS during service. Additionally, following a review of the evidence of record, and as discussed below, the Board finds that the preponderance of evidence is against a finding of a nexus between the current diagnosis of MTS and active service. Post-service treatment records submitted by the Veteran show the Veteran going to the same private physician from July 2010 to June 2015. His past medical history throughout this period of time included attention deficit disorder, acid reflux, and cold sores. The Veteran was not reporting symptoms involving his left lower extremity. An April 2013 treatment record documented that the Veteran was there for a physical for his job in security. A physical examination was performed of all bodily systems, and the musculoskeletal system showed normal range of motion, strength and tone. During the period from July 2010 to June 2015, while the Veteran reported other symptoms he was experiencing during that time, such as decreased libido, right elbow pain, insomnia, acid reflux, upper respiratory infection, and a cough, he was not reporting symptoms involving his left lower extremity, which leads to the conclusion he was not having ongoing symptoms. He presented to that examiner for annual physicals in connection with his work in April 2013, April 2014, and March 2015, and the Board finds that if he had been experiencing "severe" swelling in his ankle, he would have reported such fact, since he reported other symptoms he had experienced during that time frame about which he was concerned. VA treatment records from August 2015 document that the Veteran presented to VA for the first time and reported that he had been treated for conditions including left ankle pain and swelling, and he denied any current left ankle swelling, which is consistent with the private treatment records from July 2010 to June 2015. The Board finds that the contemporaneous records do not support ongoing left lower extremity symptoms in the years following service discharge. Upon VA ankle examination in November 2016, the Veteran reported injuring his ankle at least three times, first at a self-defense class with the USMC training, when his ankle swelled up and turned "bluish;" second, at Lackland Air Force base when doing "security forces school;" and third, at Ballad, when he developed swelling of the ankle. He stated that at Lackland be was diagnosed with "stress level 2 fracture" of the ankle but he was not casted. He reported current aches and swelling after running or prolonged standing, but denied seeing any doctors for this condition after 2010. The Veteran had reported doing vigorous exercise at least five days a week, where he would do moderate exercise at least five days a week and three days of physical activities designed to strengthen his muscles, such as lifting weights. The VA examiner concluded that the Veteran had overuse syndrome of the ankle, which was a disease with a clear and specific etiology and diagnosis, was not caused by or related to Gulf War environmental exposure, and was not caused by soft tissue injuries documented during active service that resolved as per subsequent examinations. Additionally, the examiner noted that x-rays demonstrated the same changes in both ankles, consistent with aging, and that the condition was due to using the body in a repetitious way, resulting in discomfort based on the amount done. In February 2017, the Veteran presented to the emergency room at VA straight from the airport after being overseas for work for management and evaluation of extensive left leg deep vein thrombosis (DVT) that was diagnosed in the country of Jordan approximately 7 days before. He reported that he woke up 7 days before with sudden onset of left leg pain and went to a nearby hospital for evaluation where he ended up having a CT angiogram of both his chest and his leg, which showed an extensive clot burden from the proximal left femoral vein all the way down the left leg, in addition to subsegmental pulmonary emboli as well. The Veteran initially reported some shortness of breath, but denied chest pain and noted that his shortness of breath had returned to baseline. He denied any prior blood clot in his leg or his lungs before, as well as any family history of this. He stated that he went on long airplane flights frequently for his job and that he sat around frequently. He reported increased redness, numbness, and tingling sensation to his medial left thigh area over the last 1-2 days but denied any fever. It was noted that the Veteran had been diagnosed with acute MTS and that due to the relatively recent onset, he would potentially benefit from thrombolysis. Subsequent VA treatment records from April 2017 document the Veteran's follow-up visit for stents that were placed after he developed DVT in his left lower extremity while he was overseas in Jordan and was taken to Syracuse VAMC where he was diagnosed with MTS. Given the evidence discussed above, the Board finds that the preponderance of the evidence weighs against a finding of a nexus between the Veteran's current MTS, diagnosed in 2017, and his active service, which ended in 2010. Rather, the objective medical records document that the Veteran's MTS was of "relatively recent onset" in early 2017, which the Board notes is nearly seven years after his most recent discharge from active service. It is clear from the 2017 treatment records that the Veteran had not experienced these types of symptoms previously, as the February 2017 record documented the Veteran had "never had a blood[ ]clot in his leg or lungs before" and reported that he had woken up with a sudden onset of left leg pain. The February 2017 record documented that the CT angiogram of the left leg showed "extensive clot burden from the proximal left femoral vein all the way down." In other words, the entire left leg was impacted, which is consistent with how the Veteran's representative described MTS at the May 2021 hearing, which involved the vein at the top of the lower extremity. The Board does not find that it is reasonable to conclude that ankle pain reported in 2005 and 2009 was indicative of MTS diagnosed eight years later, where the entire left leg symptoms had their onset in 2017. The Board has also considered the relevant lay evidence of record, including the Veteran's May 2021 Board hearing testimony discussed above. While the Veteran is competent to report observable symptoms, such as left ankle pain and swelling, to the extent he asserts that his current MTS is related to active service, including his in-service left ankle complaints and allegations of subsequent swelling, such statements are not probative given the Veteran's lack of medical expertise to diagnose a complex and internal condition and to render a nexus opinion relating the complaints to active service. Additionally, to the extent that the Veteran asserts that his current MTS first had its onset during active service, such statements are not corroborated by the contemporaneous evidence of record, including service treatment records, which the Board notes do not document symptoms or diagnosis of MTS, and post-service medical records, which do not document complaints or diagnosis of MTS prior to 2017. Given the manifestations of MTS as described in early 2017, the Board finds it reasonable that if the Veteran was experiencing such symptoms in the left lower extremity during active service and in the years between active service and 2017, that he would have sought treatment, as the manifestations in 2017 required emergency care and hospitalization. When seen in 2017, the Veteran reported a very recent onset of symptoms versus longstanding symptoms, and he denied experiencing these symptoms previously. As such, the Board finds that the Veteran's reports of ongoing symptoms during and since active service prior to the objective documentation in early 2017 are not credible. The Veteran was not afforded a VA examination in connection with the claim for service connection for MTS (versus the claim for service connection for a left ankle disability). VA must provide a medical examination or opinion when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, the Board finds that there is not an indication that the disability is associated with the ankle injury the Veteran sustained in 2005 or the possible swelling in his left ankle in 2009 for the reasons described above. For a VA examination to be warranted, all the criteria have to be met, and at least one criteria is not met. Therefore, entitlement to a VA examination is not warranted. For all the reasons laid out above, the Board concludes that the preponderance of evidence weighs against the Veteran's claim for service connection for MTS of the left lower extremity, including the left ankle. As such, there is no reasonable doubt to be resolved, and the claim is denied. 2. Entitlement to service connection for tinnitus. The Veteran next claims tinnitus as a result of exposure to hazardous noise during active service. At the May 2021 Board hearing, the Veteran testified that he did not suffer from ringing in the ears prior to joining the Air Force, and that he was routinely exposed to hazardous noise, as he worked in tactical aircraft maintenance, which involved work around flights day and night, and active runways for 12 hours at a time, and special security forces that involved exposure to weapons noise. He reported that he first noticed tinnitus around 1999, before he was discharged the first time, when he started having ringing in his ears about once a month. He stated that since that time, it had gotten progressively worse and that if affected his ability to deal with people in general and to hear people completely. Following a review of the evidence of record, and resolving any reasonable doubt in favor of the Veteran, the Board finds that the preponderance of evidence weighs in favor of the Veteran's claim of entitlement to service connection for tinnitus. The Board is mindful that there is no medical test for tinnitus; thus, evidence of tinnitus symptoms is highly subjective. Moreover, tinnitus is a condition capable of lay observation and the Veteran is competent to report that he has tinnitus. See Charles v. Principi, 16 Vet. App. 370, 374 (2002). As such, based upon Veteran's lay reports as documented in the record and during the pendency of his claim, the Board finds that the facts establish that the first criterion of a service connection claim, the requirement of a current disability, is met. Regarding the in-service element of his claim, the Board notes that service treatment records include an August 1999 reference audiogram that documents the Veteran was routinely exposed to hazardous noise. Similarly, a concurrent August 1999 Hearing Conservation Examination documents that the Veteran reported that he had ringing in his ears. Additionally, within a June 2010 Report of Medical Assessment, shortly after his discharge from active service, the Veteran again reported persistent ringing in his ears and bilateral tinnitus. Given the above, the Board finds that the in-service element of the Veteran's claim has been met. Moreover, the Veteran's military occupational specialty (MOS) in Tactical Aircraft Maintenance has been determined by VA to have a high probability of hazardous noise exposure. Regarding a nexus to active service, post-service VA treatment records from August 2015 document that the Veteran presented to the VA for health care for the first time and reported tinnitus. Similarly, he reported chronic tinnitus later in February 2019. Upon VA audiology examination in November 2016, the Veteran reported that his tinnitus began "years and years ago" although the exact date of onset was unknown. He described the condition as a periodic bilateral ringing sound, occurring an average of two to three times per month. Although the VA examiner ultimately opined that the Veteran's tinnitus was less likely than not caused by or a result of military noise exposure, the Board notes that the examiner inaccurately stated that there was no complaint of tinnitus noted in the Veteran's service treatment records. As noted above, an August 1999 hearing conservation examination documents the Veteran's report of tinnitus. As such, the Board finds the November 2016 negative nexus opinion to be of limited probative value, as it is based upon an inaccurate fact. Additionally, the Board has considered the Veteran's May 2021 Board hearing testimony that he was exposed to hazardous noise throughout active service, which resulted in tinnitus that was present during active service, within the first year of his discharge from active service in June 2010, and thereafter as noted upon VA examination in November 2016. Absent a reason to question the Veteran's credibility regarding his reports of tinnitus, and resolving reasonable doubt in favor of the Veteran, the Board finds that his reports are probative evidence of tinnitus that had its onset during active service and has continued to manifest to a compensable degree. As such, there is probative evidence of a nexus to service. Given the above, the Board finds that the Veteran's claim for service connection for tinnitus is granted. 3. Entitlement to service connection for gastroesophageal reflux disease (GERD). The Veteran also claims that GERD is due to his active service. At the May 2021 Board hearing, the Veteran testified that he did not exhibit GERD symptoms prior to joining the Air Force and stated that he first noticed GERD symptoms around 1999, which progressively increased to require lifelong medication. Following a review of the evidence of record, and resolving any reasonable doubt in favor of the Veteran, the Board finds that the preponderance of evidence weighs in favor of the Veteran's claim of entitlement to service connection for GERD. Post-service VA treatment records document the Veteran's gastrointestinal complaints and a diagnosis of GERD. As such, the Board finds that the facts establish that the first criterion of a service connection claim, the requirement of a current disability, is met. Regarding the in-service element of his claim, the Board notes that service treatment records document that within a February 2010 Post-Deployment Health Assessment, the Veteran complained of GERD and stated that he was still bothered by frequent indigestion/heartburn. Given the above, the Board finds that the in-service element of the Veteran's claim has been met. Additionally, post-service treatment records weigh in favor of a finding of a nexus between the Veteran's current GERD and his active service. Notably, post-service VA treatment records from June 2010, just one month after his discharge from active service, the Veteran underwent an endoscopy for a pre-operative diagnosis of GERD. The procedure found significant reflux, which the Veteran reported that he had substernal burning for quite some time that was much more noticeable for the last year. He reported that he took Nexium as needed. The resulting impression was GERD by history, and linear erythema consistent with Los Angeles Grade A esophagitis. Upon follow up in July 2010, the Veteran reported ongoing acid reflux and the resulting assessment was GERD. Similarly, in July 2012, the Veteran reported a history of hiatal hernia that required Nexium, and again the noted assessment was GERD. Later, in August 2015, when the Veteran presented to VA for health care, he reported that he had been treated for GERD and requested Omeprazole. Upon VA examination in November 2016, the Veteran reported that he was diagnosed with GERD and hiatal hernia sometime in 2007 after having a gastroscopy. The VA examiner stated that hiatal hernia and GERD were a disease with a clear and specific etiology and diagnosis, were not caused by or related to Gulf War environmental exposure, and were not present on endoscopy performed in 2007. The examiner stated that current studies demonstrated no reflux and that the Veteran's reported symptomatology was most likely due to dietary indiscretions, while hiatal hernia was a developmental condition and normally asymptomatic. Notably, the examiner did not consider the Veteran's in-service complaints of GERD and ongoing symptoms thereafter, documented as recent as one month after service discharge in June 2010 and continuing to the present. As such, the Board finds that the November 2016 negative nexus opinion is of limited probative value. Subsequent VA treatment records from February 2018 again document the Veteran's symptoms of GERD and prior EGD with findings of gastritis. In July 2018, his history of GERD and dysphagia were again noted, for which he took daily pantoprazole medication. In July 2019, an endoscopy revealed non-esophagitis-related reflux disease (NERD). Finally, VA treatment records from February 2021 document that the Veteran was referred for GERD. He reported reflux for the past 2-3 years, with treatment by Protonix since then. His reflux symptoms were well-controlled on the medications with minimal to no breakthrough events. Following a review of the evidence of record, the Board finds that the above post-service evidence is probative establishing a nexus to active service, as the Veteran's GERD first manifested during active service, as documented within service treatment records from February 2010, and has continued to the present time. To the extent that the November 2016 VA examiner failed to find a nexus between the Veteran's current complaints and his active service, the Board resolves any reasonable doubt in favor of the Veteran and finds that the post-service complaints of GERD cannot be disassociated with the documented in-service complaints of GERD. As such, and in conclusion, after considering the above evidence of record, and resolving reasonable doubt in favor of the Veteran, the Board concludes that service connection for GERD is warranted, and the Veteran's claim for service connection for GERD is granted. A. P. SIMPSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Chad Johnson, 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.