Citation Nr: 21021891 Decision Date: 04/14/21 Archive Date: 04/14/21 DOCKET NO. 15-41 913 DATE: April 14, 2021 ORDER Entitlement to service connection for vitiligo is granted. Entitlement to service connection for bilateral ankle disability is granted. FINDINGS OF FACT 1. The Veteran’s vitiligo was at least as likely as not incurred during service. 2. The Veteran’s bilateral ankle disability was at least as likely as not incurred during service. CONCLUSIONS OF LAW 1. The criteria to establish entitlement to service connection for vitiligo have been met.  38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria to establish entitlement to service connection for a bilateral ankle disability have been met.  38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran serviced in the U.S. Air Force from August 1975 to August 1979. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a December 2013 rating decision issued by the Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ). The matter was previously before the Board in December 2019 and August 2020, at which time it was remanded for development. The case was returned to the Board for appellate review in December 2020. The Veteran was scheduled for a hearing in March 2019. However, the Veterans Appeals Control Locator System (VACOLS) indicates that his hearing request was withdrawn. Although a formal written request is not found in the Veteran’s electronic claims file, given the Veteran’s representative submitted an informal hearing presentation in August 2019 without request for a hearing, the Board finds that the Veteran’s hearing request has been withdrawn. See 38C.F.R. §20.704. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Entitlement to service connection requires: (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the in-service disease or injury and the current disability. 38C.F.R. §3.303(a); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any disease initially diagnosed after service 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). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that “[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional.” Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (“[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence”). Service connection must be considered on the basis of the places, types, and circumstances of his service as shown by his service records, the official history of each organization in which he or she served, his or her medical records, and all pertinent medical and lay evidence. See 38 C.F.R. § 3.303(a); see also Jandreau, 492 F.3d at 1377; and Buchanan, 451 F.3d at 1337. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). 3. Entitlement to service connection for vitiligo The Veteran maintains that his vitiligo manifested during service from radiation exposure and has continued thereafter. The Board finds that the elements of entitlement to service connection for vitiligo have been met. With respect to current diagnosis, the record reveals that the Veteran has been diagnosed and treated for vitiligo by a dermatologist. Two VA examiners also document a diagnosis for vitiligo in examination reports from May 2018 and October 2020. This evidence demonstrates that the first element of service connection has been satisfied. With regard to in-service incurrence, the Veteran has consistently reported that vitiligo first manifested during service. For example, he reported during a VA dermatology consultation in October 2007 that he has had pigment loss in the neck region for about 30 years, starting in the mid-1970s. Similarly, the Veteran told his primary care doctor in November 2007 that he has had white blotches on his skin in the neck region for about 30 years. The Board finds that the Veteran is competent to report these symptoms as they are readily observable to a lay person.  38 C.F.R. § 3.303(a); see also Jandreau, 492 F.3d at 1377. Furthermore, the Board finds no reason to doubt the credibility of these statements, as they are consistent with statements he has made since filing his initial claim for service connection in February 2008. Accordingly, the Board finds that the Veteran’s competent and credible lay statements sufficiently establish the in-service incurrence element of this claim. The remaining question is whether there is a nexus between the Veteran’s in-service exposure and his current vitiligo. The record contains two negative opinions addressing a nexus. In May 2018, a VA examiner concluded that the Veteran’s vitiligo was less likely than not caused by facial skin problems, pseudofolliculitis barbae (PFB), pruritis, acne, blisters, emotional distress, and allergies treated during service. The examiner further indicated that the exact cause of vitiligo is unknown, but the disorder is associated with autoimmune disorders. She then concluded that vitiligo has no association with and is not related to PFB, pruritis, acne, blisters, emotional distress, or allergies. In October 2020, another VA examiner concluded that the Veteran’s vitiligo was less likely than not incurred in or caused by service. This examiner reasoned that there was no diagnosis or concerns for vitiligo noted during active duty. The examiner further reasoned that the medical literature does not show that vitiligo is caused by ionizing radiation of any strength and indicated that the Mayo Clinic listed autoimmune conditions, heredity, and a trigger event (such as stress and severe sunburn or skin trauma, such as contact with a chemical) as causes of vitiligo. Contrary to these opinions, the Veteran reported during a dermatology consultation in October 2007 that he began experiencing loss of pigment in the neck region in the mid-1970s. He elaborated that the hypopigmented areas have increased in size and number of spots, becoming more noticeable over the years. The Board finds that the Veteran is competent to report the onset and continuity of his symptoms.  38 C.F.R. § 3.303(a); see also Jandreau, 492 F.3d at 1377. Moreover, the Board finds no reason to doubt the credibility of these statements. The Veteran’s statements were made during the course of treatment and before he filed his initial claim for service connection. Furthermore, his statements have been consistent with those he has made throughout his appeal. Neither VA examiner addressed these competent and credible lay statements made by the Veteran regarding his continual symptoms since service. Additionally, the May 2018 VA examiner failed to acknowledge in her opinion a notation she made in the Veteran’s medical history that the vitiligo onset was 1979 and is characterized as persistent on the forearms and neck. Furthermore, the October 2020 VA examiner citied stress as a cause of vitiligo listed by the Mayo Clinic. However, this examiner did not address the Veteran’s service-connected psychiatric disability, which includes an unspecified trauma and stressor related disorder. It is noteworthy that an April 2018 VA examiner concluded that the Veteran’s psychiatric symptoms began around May 1976 and acute psychosis had manifested by 1977. Because these nexus opinions are based on an inaccurate factual premise, they are inadequate and have no probative value. See Reonal v. Brown, 5 Vet. App. 548 (1993). While there is no adequate negative nexus opinion, the competent and credible statements made by the Veteran are highly probative in establishing a nexus. See 38 C.F.R. § 3.303(a) (service connection must be considered on the basis of the places, types, and circumstances of his service as shown by his service records, the official history of each organization in which he served, his medical records, and all pertinent medical and lay evidence); see also Buchanan, 451 F.3d at 1335 (“[N]othing in the regulatory or statutory provisions [relating to evidence to be considered] require both medical and competent lay evidence; rather, they make clear that competent lay evidence can be sufficient in and of itself”). Furthermore, the October 2020 VA examiner’s notation that stress is a cause of vitiligo listed by the Mayo Clinic, considered in combination with the Veteran’s confirmed in-service stressor, is highly probative evidence with respect to establishing a nexus. The May 2018 VA examiner notation that the Veteran’s vitiligo is persistent and had its onset in 1979 is also probative with respect to establishing a nexus. Accordingly, the Board finds that the most probative evidence of record establishes a nexus between service and the Veteran’s current vitiligo. Based on the foregoing, the weight of the evidence supports finding that the Veteran’s vitiligo was incurred during his active service. As such, service connection is granted. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102; 3.303(d). In light of this grant of service connection, the Board need not address the Veteran’s theory of entitlement based on radiation exposure. 4. Entitlement to service connection for bilateral ankle disability The Veteran maintains that his bilateral ankle disability manifested during service and that his symptoms have continued since discharge. The Board finds that the elements of entitlement to service connection for a bilateral ankle disability have been met. With respect to current diagnosis, the record reveals that the Veteran reported chronic ankle pain bilaterally during treating visits in 2012. Diagnostic imaging was performed in August 2012 and revealed evidence of a stress fracture and tenosynovitis involving the posterior tibialis tendon of the left ankle. At this time, an orthopedic physician diagnosed the Veteran with left ankle pain and mild instability. In subsequent treating visits, the Veteran reported having ongoing problems with pain in both ankles. In December 2019, the Veteran underwent a VA examination and he exhibited functional loss due to pain of the ankles bilaterally. At this time, the VA examiner diagnosed the Veteran with a chronic and recurrent deltoid ligament sprain affecting both ankles. This evidence demonstrates that the first element of service connection has been satisfied. With respect to in-service incurrence, the Veteran maintains that his ankle pain began while duck walking across aircraft carriers during service. The Board notes that the Veteran is competent to report symptoms and observable events within the realm of his personal knowledge. Layno v. Brown, 6 Vet. App. 465, 470-471 (1994); Jandreau, 492 F.3d at 1377. Furthermore, the Veteran’s statements pertaining to the nature of his work are credible, as they are consistent with personnel records documenting his military occupational specialty (MOS) as a tactical aircraft maintenance specialist. Accordingly, the Board finds that the Veteran’s competent and credible lay statements sufficiently establish the in-service incurrence element of this claim. The remaining question is whether there is a nexus between the Veteran’s in-service exposure and his current bilateral ankle disability. The record contains two negative opinions addressing a nexus. In December 2019, a VA examiner concluded that the Veteran’s bilateral ankle disability was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner reasoned that the Veteran’s service treatment records (STRs) and separation examination did not document any complaints of ankle pain or injury. The examiner further reasoned that the Veteran did not have surgery on his left ankle until 2013, which is over 30 years after his discharge. Another VA examiner also concluded that the Veteran’s bilateral ankle disability was less likely than not incurred in or caused by the claimed in-service injury, event, or illness in December 2020. The examiner elaborated that the Veteran’s lay statements for chronicity and cause of current complaints are not supported by the evidence. She noted that the Veteran’s STRs showed no chronic foot or ankle complaints and the Veteran did not receive treatment for ankle pain until 2009. The examiner further noted, “surely if foot complaints were as troubling as noted in remand, the veteran would have reported them, yet there are none despite ample opportunity to do so.” Contrary to these opinions, the Veteran reported during treating visits that his ankle pain dated back to service. In October 2012, the Veteran reported during an orthopedic consultation that “he has had discomfort with his ankles for years going back to his active duty military service from 1975 through 1979.” Similarly, the Veteran reported during a surgical consultation in December 2012 that he has had longstanding issues since his days of service in the Air Force when he had to duck walk across carriers. The Board finds that the Veteran is competent to report the onset and continuity of his symptoms.  38 C.F.R. § 3.303(a); see also Jandreau, 492 F.3d at 1377. Moreover, the Board finds no reason to doubt the credibility of these statements, as they were made during the course of treatment. Because neither VA examiner opinion addresses the Veteran’s reports to treating providers regarding his continual symptoms since service, they are inadequate and have no probative value. See Reonal v. Brown, 5 Vet. App. 548 (1993). Given that there is no adequate negative opinion, the competent and credible statements made by the Veteran is the most probative evidence of record. See 38 C.F.R. § 3.303(a) (service connection must be considered on the basis of the places, types, and circumstances of his service as shown by his service records, the official history of each organization in which he served, his medical records, and all pertinent medical and lay evidence); see also Buchanan, 451 F.3d at 1335 (“[N]othing in the regulatory or statutory provisions [relating to evidence to be considered] require both medical and competent lay evidence; rather, they make clear that competent lay evidence can be sufficient in and of itself”). Accordingly, the Board finds that the most probative evidence establishes a nexus between service and the Veteran’s current bilateral ankle disability. In sum, the weight of the evidence supports finding that the Veteran’s bilateral ankle disability was incurred during his active service, and service connection is granted. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102; 3.303(a), (d). GAYLE STROMMEN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Beech, 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.