Citation Nr: 21007499 Decision Date: 02/09/21 Archive Date: 02/09/21 DOCKET NO. 19-37 366 DATE: February 9, 2021 ORDER Service connection for status post right ankle osteomyelitis with right below the knee amputation is denied. FINDING OF FACT The preponderance of the evidence is against finding that the Veteran’s status post right ankle osteomyelitis with right below the knee amputation is caused or aggravated by his service-connected right lower extremity peripheral neuropathy. CONCLUSION OF LAW The criteria for entitlement to service connection for status post right ankle osteomyelitis with right below the knee amputation have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from April 1961 to May 1962. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a September 2017 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the claim in March 2020 to obtain an addendum medical opinion. The Board finds substantial compliance with the remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). This claim has been advanced on the docket (AOD) pursuant to 38 C.F.R. § 20.900(c); 38 U.S.C. § 7107 (a)(2). Service connection for right ankle osteomyelitis is denied. The Veteran contends that his right ankle osteomyelitis, which led to a right below the knee amputation, was due to his service-connected peripheral neuropathy of the right lower extremity. Specifically, the Veteran asserts that he developed osteomyelitis in his right ankle following a brown recluse spider bite, which he initially did not feel because of the severity of his right lower extremity peripheral neuropathy. See Form 9 (November 2019); NOD (October 2017). The Board notes the Veteran has been in receipt of a 40 percent rating from March 2010 for moderately severe peripheral neuropathy of the right lower extremity. The Board concludes that, while the Veteran is diagnosed with status post right ankle osteomyelitis with a right below the knee amputation, the preponderance of the evidence is against finding that the disability is proximately due to or the result of, or aggravated beyond its natural progression by his service-connected peripheral neuropathy of the right lower extremity. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310(a). Because the Veteran has not raised, and the record does not reasonably raise, entitlement to direct service connection, the Board’s adjudication will consider only entitlement to secondary service connection. To establish a claim for entitlement to secondary service connection, a veteran must have (1) a current disability that is not already service-connected; (2) at least one service-connected disability; and (3) evidence that the non-service-connected disability is either proximately due to or the result of a service-connected disability, or, aggravated beyond its natural progression by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). The Veteran’s VA treatment records show that he was seen in October 2016 presenting with redness, swelling and white discharge from his right lower leg and ankle. He reported that he was working in his yard earlier in the week when he was stung by several fire ants. He stated that, over the past couple of days, the ankle became tender, red and swollen. Notably, the Veteran stated that he noticed there had been some drainage that was thick and “pus-like” at first but now it was bubbly and thinner, and he had applied peroxide to the area for a couple of days. Following the visit, the Veteran was assessed with cellulitis of the right lower leg and ankle “which may have erupted following fire ant stings.” A March 2017 VA treatment record notes the Veteran complained of a sore right ankle and reported that he was treated for a spider bite six months ago, but the area continued to drain. In September 2017, prior to undergoing a below the knee amputation in March 2018, the Veteran was afforded a VA ankle conditions examination and he was diagnosed as having osteomyelitis of the lateral aspect of the lateral right malleolus. The Veteran reported that he believed he had been bitten on the right ankle by a venomous spider. The examination report incorporated a right ankle x-ray report dated April 2017 that revealed persistent significant soft tissue swelling over the lateral malleolus. A right ankle x-ray from September 2017 showed internal development of cortical destruction with adjacent periosteal reaction in the distal tip of the fibula and it was noted that the findings were likely secondary to osteomyelitis as per clinical history. The examiner opined that the Veteran’s current right ankle disability was not caused by or a result of his service-connected peripheral neuropathy. Rather, the examiner concluded that, based on the Veteran’s report that a brown recluse spider bit his ankle one year prior, it was likely the right ankle osteomyelitis was caused by the spider’s venom, as literature has shown that this species causes bacterial infections and osteomyelitis. A VA treatment record dated April 2018 shows a primary care physician reviewed the Veteran’s non-VA progress notes dated February 2018 and March 2018 and noted the Veteran had been seen for a chronic ulcer on the right ankle. X-rays showed osteomyelitis of the distal fibula and an MRI showed osteomyelitis of the distal fibula and lateral calcaneus plus torn peroneal tendons. The Veteran underwent a right below the knee amputation in March 2018 that was performed by his private physician. A VA treatment record from November 2018 noted the Veteran had a history of a brown recluse spider bite to the right foot that required a below the knee amputation in the absence of any history of diabetes mellitus or peripheral vascular disease. The Veteran was afforded a VA amputations examination in October 2020 and the examiner, a medical doctor, diagnosed him with status post right ankle osteomyelitis with right below the knee amputation. The VA examiner noted a VA x-ray dated July 2017 showing osteomyelitis of the lateral aspect of the lateral malleolus. The examiner stated the Veteran underwent a below the knee amputation in 2018 because of the condition. In response to the Board’s remand, the VA examiner provided a medical opinion on the question of whether the Veteran’s service-connected right lower extremity peripheral neuropathy aggravated or worsened his nonservice-connected osteomyelitis beyond its natural progression. El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013) (a medical opinion addressing secondary service connection must assess not only if the claimed disability was caused by the service-connected disability, but also if it was aggravated by that service-connected disability). The VA examiner opined that it was less likely than not that the Veteran’s right ankle osteomyelitis with right below the knee amputation was aggravated beyond its natural progression by peripheral neuropathy of the right lower extremity. The examiner indicated that the neuropathic condition would not have any bearing on the progression of the infectious process which led to osteomyelitis and ultimately the below the knee amputation. The examiner acknowledged that peripheral neuropathy can cause numbness in an area and reduce the ability to physically recognize pain or infection in that same area. However, in this case, VA treatment records reflect that at the time he sought care at the VA hospital on October 28, 2016, the Veteran was well aware that one week prior, he had been bitten. In addition, he noticed potential complications (worsening of symptoms) and subsequently treated the area of infection. The examiner indicated that the Veteran’s actions suggest there was no significant delay in noticing his right ankle symptoms following the bite. The Board recognizes the Veteran’s belief that his right ankle osteomyelitis was proximately due to or the result of decreased sensation in his right leg from his service-connected peripheral neuropathy. While the Veteran is competent to report symptomatology that he experiences, he has not shown that he has the medical experience or training to relate his osteomyelitis to his peripheral neuropathy, which is a medically complex determination that cannot be based on lay observation alone. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Instead, such a determination must be made by a medical professional with appropriate expertise. Id. Therefore, the Veteran's nexus lay statements relating the residuals of a spider bite to the lack of sensation in his right leg due to peripheral neuropathy are not competent evidence in this case. Further, even if such were competent, the Veteran’s report of lack of feeling to notice the initial bite, whether fire ants or recluse spider, is not credible given his contemporaneous reports. In this regard, VA treatment records indicate that he was aware he had been bitten by an insect on his right ankle shortly after the incident occurred in October 2016. Hence, the Veteran’s argument that the severity of his service-connected peripheral neuropathy caused the bite(s) to go unnoticed is not credible. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than history as reported by the veteran). Consequently, the Board assigns higher probative weight to the October 2020 VA examiner’s opinion. The opinion was provided by a VA medical doctor who possesses the necessary education, training, and expertise to provide the requested opinion. Additionally, the opinion is based on the examiner’s review of the Veteran's claims file, in-person examination and interview of the Veteran, and an accurate recitation of the relevant facts in the case. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000); Nieves-Rodriguez, 22 Vet. App. 295. The Board further affords greater probative value to the Veteran’s contemporaneous VA treatment records indicate that he was aware he had been bitten by an insect on his right ankle shortly after the incident occurred in October 2016. Here, the preponderance of the competent and credible evidence shows neither shows causation nor aggravation of the Veteran’s right ankle osteomyelitis by a service-connected disability. On balance, the weight of the evidence is against the claim for service connection for status post right ankle osteomyelitis with a right below the knee amputation, as due to his service-connected right lower extremity peripheral neuropathy. Accordingly, the claim is denied. As the evidence of record is not roughly in equipoise, there is no doubt to resolve. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Krunic, 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.