Citation Nr: 21021710 Decision Date: 04/13/21 Archive Date: 04/13/21 DOCKET NO. 12-15 941 DATE: April 13, 2021 ORDER Service connection for a bilateral lower extremity disorder is denied. FINDING OF FACT A bilateral lower extremity disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service, to include exposure to herbicide agents, and is not caused or aggravated by a service-connected disability. CONCLUSION OF LAW The criteria for service connection for a bilateral lower extremity disorder have not been met. 38 U.S.C. §§ 1110, 1116 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from August 1967 to September 1970. He is the recipient of numerous awards and decorations, to include the Combat Infantryman Badge. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a rating decision issued in May 2010 by a Department of Veterans Affairs (VA) Regional Office. In July 2015, the Veteran and his spouse testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record on appeal. In October 2015, January 2018, and July 2020, the Board remanded the case for additional development and it now returns for further appellate review. Entitlement to service connection for bilateral lower extremity disorder, to include as due to exposure to herbicide agents and/or as secondary to service-connected coronary artery disease (CAD). Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff’d, 78 F.3d 604 (Fed. Cir. 1996). The law also provides a presumption of service connection for certain diseases associated with exposure to herbicide agents that become manifest to a specified degree within a specific time period, even if there is no record or evidence of such disease during service. 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307, 3.309. As the Veteran served in the Republic of Vietnam from March 1968 to March 1969, he is presumed to have been exposed to herbicide agents coincident with such service. 38 U.S.C. § 1116; 38 C.F.R. § 3.307(a)(6). However, as will be discussed below, he does not have a current diagnosis of a disease acknowledged to be presumptively related to such in-service exposure. Nevertheless, he is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Further, service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310(b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.R.F. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). In documents of record and at his July 2015 Board hearing, the Veteran contended he has a bilateral lower extremity disorder related to service, to include his presumed exposure to herbicide agents. Alternatively, he asserts he has a bilateral lower extremity disorder proximately due to and/or aggravated by his service-connected CAD. In this regard, the record reflects that the Veteran has a current bilateral lower extremity disorder, variously diagnosed as venous insufficiency, varicose veins, and dependent edema. See September 2016 VA examination report. Furthermore, his service treatment records are negative for any complaints, treatment, or diagnosis of a bilateral lower extremity disorder, and he did not present with complaints related to such disorder until 1999, which is almost 30 years after his separation from service. In this regard, while his representative alleged in his March 2021 Written Brief Presentation that varicose veins were present in service as evidenced by the presence of hemorrhoids, the fact remains that there was no bilateral lower extremity disorder documented therein. Furthermore, September 2016 and September 2020 VA examiners found that there was no evidence in the Veteran’s service treatment records to suggest that he had a bilateral lower extremity disorder while in service, or that such disorder was otherwise directly related to service. Nonetheless, as noted previously, he is presumed to have been exposed to herbicide agents coincident with his service in Vietnam and he is currently service-connected for CAD. However, the September 2016 VA examiner opined the Veteran’s venous insufficiency in the lower extremities was most likely due to incompetent valves, obesity, and family history. Similarly, in June 2019, another VA examiner found that the Veteran’s diagnosis of chronic venous insufficiency was not at least as likely as not incurred in or caused by an in-service event or injury, to include exposure to herbicide agents, as such was not found to be presumptively related to such exposure. In September 2019, another VA examiner also opined the Veteran’s venous insufficiency was not related to his in-service herbicide exposure, and in September 2020, the same VA physician opined his varicose veins were less likely as not caused by, or incurred during, his military service. As rationale, the VA physician reported that the Veteran’s varicose veins were a result of his nonservice-connected venous insufficiency, which caused pooling of blood over time with aging and caused veins to become enlarged or dilated, and there was no evidence in the service treatment records to support a nexus between service and venous insufficiency or varicose veins. With respect to the Veteran’s alternative theory of entitlement, the September 2016 VA examiner opined the Veteran’s congestive heart failure and CAD were not likely the cause of his venous insufficiency based on the results of his echocardiogram. Rather, he found that the Veteran’s venous insufficiency was most likely due to incompetent valves, obesity, and family history. In this regard, the VA examiner reported there was no medical literature to support CAD as the etiology of venous insufficiency. In May 2017, a VA physician opined it is less than likely that the Veteran’s lower extremity condition with venous insufficiency, swelling, and fluid retention is secondary to his service-connected CAD. In this regard, he explained that it is impossible to relate the two pathophysiologically as venous insufficiency and CAD are two separate and distinct disease entities. The VA examiner explained that venous insufficiency is a disease of the venous system and is due to incompetent valves in the lower extremity venous system, which can be due to hereditary factors and caused/aggravated by obesity. Conversely, he reported that CAD is a disease of the arterial system in the heart and is due to blockage of the arteries in the heart. Similarly, the July 2019 VA examiner found that it is not at least as likely as not that any bilateral lower extremity disorder is aggravated by the Veteran’s service-connected CAD. In this regard, he explained that such conditions have different causes and pathophysiologies, with chronic venous insufficiency affecting the lower extremities and CAD affecting the heart arteries. Likewise, the September 2019 VA examiner reported that swelling in the lower extremity was less likely as not proximately due to or a result of the Veteran’s service-connected CAD. In this regard, he explained that venous insufficiency is a separate, unrelated medical diagnosis and that the Veteran’s ABI test was negative for peripheral arterial disease of the bilateral extremities. In July 2020, the same VA examiner explained that venous insufficiency is a separate and distinct entity from CAD and is not aggravated beyond its natural progression by service-connected CAD. Upon review, the Board affords significant probative value to the aforementioned opinions, when considered together, as such contemplated the pertinent evidence of record, to include the Veteran’s statements, his relevant medical history, and relevant medical literature, and provided rationales, relying on and citing to the records reviewed. Moreover, the clinicians offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A]medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions”). Further, the clinicians clearly considered the Veteran’s specific case, providing an alternative etiology of incompetent valves, obesity, and family history for his current bilateral lower extremity disorders. Notably, there is no competent opinion to the contrary. In this regard, the Board has considered the Veteran’s assertions as to the etiology of his current bilateral lower extremity disorders; however, as a lay person, he does not have the requisite training and experience necessary to address such a complex medical matter. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). Rather, the etiologies of such disorders involve a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. Specifically, such requires knowledge of the venous and arterial systems. Therefore, such matters may not be competently addressed by lay statements. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (explaining that while the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Thus, the Veteran’s opinion as to the onset and etiology of his current bilateral lower extremity disorders is not competent evidence and, consequently, is afforded no probative weight. The Board further notes that, in his March 2021 Written Brief Presentation, the Veteran’s representative argued that, while the Veteran was service-connected for an anxiety disorder, he also appeared to have posttraumatic stress disorder (PTSD) and cited medical articles suggesting that PTSD was linked to several risk and causal factors for venous insufficiency such as physical inactivity, weight gain, and hypertension. However, as noted by the Veteran’s representative, he is not service-connected for PTSD; rather, he is service-connected for anxiety disorder. Furthermore, he is not service-connected for hypertension and, as discussed at length previously, his service-connected CAD is not show to have caused or aggravated his bilateral lower extremity disorder. Moreover, the general medical literature cited by the Veteran’s representative is not accompanied by any corresponding clinical evidence specific to the Veteran. Further, such does not suggest a generic relationship between the Veteran’s current bilateral lower extremity disorder and his service-connected anxiety disorder with a degree of certainty such that, under the facts of this specific case, reflects plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion. Consequently, such literature is insufficient to establish service connection for a bilateral lower extremity disorder. Wallin v. West, 11 Vet. App. 509 (1998); Sacks v. West, 11 Vet. App. 314 (1998); Libertine v. Brown, 9 Vet. App. 521 (1996). Similarly, it is insufficient to indicate a relationship between the Veteran’s service-connected anxiety disorder and his bilateral lower extremity disorder such that VA’s duty to obtain an examination or opinion has been triggered as it is tantamount to generalized lay statement. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Waters v. Shinseki, 601 F.3d 1274, 1278 (2010) (a mere conclusory generalized lay statement that a service event or illness caused the Veteran’s current disorder is insufficient to require the Secretary to provide an examination). Thus, the Board finds the Veteran’s representative’s arguments to be without merit. In conclusion, a bilateral lower extremity disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service, to include exposure to herbicide agents, and is not caused or aggravated by a service-connected disability. Consequently, service connection for such disorder is not warranted. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claim for service connection for a bilateral lower extremity disorder. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. A. JAEGER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. M. Celli, 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.