Citation Nr: 21025782 Decision Date: 04/29/21 Archive Date: 04/29/21 DOCKET NO. 14-02 167 DATE: April 29, 2021 ORDER Entitlement to service connection for varicose veins, right lower extremity is granted. FINDING OF FACT The evidence is at least evenly balanced as to whether the Veteran’s current right lower extremity varicose veins had their onset in service. CONCLUSION OF LAW With reasonable doubt resolved in favor of the Veteran, the criteria for entitlement to service connection for varicose veins, right lower extremity have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from June 1968 to June 1971 with service in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In January 2017, the Veteran testified at a Board videoconference hearing before the undersigned Veterans Law Judge. A hearing transcript is of record. In November 2017 and October 2019, the Board remanded this claim for additional development. The development has been completed, and the case has returned to the Board. Right lower extremity varicose veins Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). 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.F.R. § 3.102. Service treatment records (STRs) include a May 1968 enlistment examination and report of medical history. As relevant, the Veteran disclosed that he had varicose veins removed from his left leg in March 1968 and was currently asymptomatic. The enlistment examination showed that the Veteran’s lower extremities were clinically evaluated and deemed normal. Accordingly, the Board finds that the presumption of soundness applies with respect to the Veteran’s right lower extremity. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). The Veteran had a separation examination in March 1971. It noted a left lower extremity scar from a vein stripping procedure prior to service. In June 1971, the Veteran signed a statement that there had been no change in his medical condition since the separation examination. In his August 2010 claim, the Veteran reported that he injured his right leg playing football in Germany. Another player fell on his leg, and he immediately developed a bruise on the inside of his right calf. The area remained puffy even after the bruise went away and turned into a varicose vein. He thought it was a minor problem and did not seek medical attention. In July 2011, the Veteran’s wife stated that she first met the Veteran in September 1971. She remembered that he had a small varicose vein in his right leg. It had grown through the years. In July 2011, the Veteran submitted a disability history report substantially similar to the one given in August 2010. At the January 2017 Board hearing, the Veteran dated his right leg varicose veins to an in-service football injury to his right calf. He reported that he initially had a bruise that turned into varicose veins. He asserted that this disability would have been reported on a separation examination if he had one. His wife also testified that right after separation she noticed that the Veteran had varicose veins on his right leg. In March 2018, the Veteran had a VA varicose vein examination with a physician. The physician diagnosed varicose veins, right lower extremity. He noted the Veteran’s report about the military football injury to his right leg. He provisionally furnished a negative medical opinion but requested that medical records concerning right leg trauma be forwarded to him for review. In an addendum, he noted causes of varicose veins including venous valvular incompetencies from reflux of blood, deep vein thrombosis (DVT), obesity, immobility and strong family history. In July 2019, the Veteran’s wife stated that the Veteran had a very noticeable varicose vein on his right leg when he returned home from service. In June 2020 a VA medical opinion was obtained from a different physician. He issued a negative determination. He stated that the medical records did not reference varicose vein in service or within the first post service year. He stated that he was unable to relate the trauma reported by the Veteran to causation of varicose veins based on pathophysiologic relationships. In April 2021, the Veteran again recounted the military football injury and that he did not seek medical attention since he believed it was a minor problem. He noted his wife attested to her memory about the presence of his right leg varicose vein immediately after service and that his decreased parents would too if they were alive. For the following reasons, service connection for right lower extremity varicose veins is warranted. The disputed issue is whether there is a relationship between service and the current right lower extremity varicose veins. The Veteran and his wife are competent to report about their observations of varicose veins being present in the Veteran’s right leg since this disorder is readily observable. Barr v. Nicholson, 21 Vet. App. 303, 308-9 (2007) (lay person competent to identify varicose veins). They are not competent to report about the medical cause given the internal pathology and complexity of venous disease. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Here, the Veteran asserts that he first developed right lower extremity varicose veins in service following a football injury, and it has continued since then. The Veteran is not competent to state that a specific football injury was the cause of varicose veins, but he and his wife are competent to report about right leg varicose veins appearing in service. Id. The Board must now consider the probative value of the Veteran and his wife’s reports about continuous symptoms starting in service to the extent they are competent. STRs, including a March 1971 physical examination, do not make any reference to varicose veins. However, the Veteran explained that he thought it was a minor problem during service and did not want to delay his separation. His explanation makes sense. The Board also notes that the separation examination occurred approximately three or four months prior to the Veteran’s actual separation. There is no evidence to suggest that the Veteran’s or wife are otherwise unreliable historians. With these considerations, the Board finds the evidence about continuous symptoms for right lower extremity varicose veins starting in service to be at least evenly balanced and entitled to some probative value in showing a relationship to service for the current disability. The medical evidence consists of the March 2018 and June 2020 VA medical opinions. The VA physicians substantially relied on the absence of treatment or report in STRs to support their negative determinations. However, in-service medical treatment is not required to establish a relationship to service and cannot by itself be used to reject the Veteran’s reports about continuous symptoms. Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). The March 2018 VA physician’s comments raised the possibility that a traumatic injury could be a cause for varicose veins, but the June 2020 VA physician’s comments indicate that the injury described by the Veteran could not. However, there is no requirement that an in-service injury be the cause of the onset of a disease in service. Rather, service connection is warranted for any disease that has its onset in service, regardless of cause. 38 C.F.R. § 3.303(a) ("Service connection connotes many factors but basically it means that the facts, shown by evidence, establish that a [condition] was incurred coincident with service in the Armed Forces.’). See also Dallas v. McDonough, No. 20-1215, 2021 U.S. App. Claims LEXIS 235, *4 (Feb. 18, 2021) (mem dec., Falvey, J.) (noting that the question for the Board in a direct service connection case is “not whether military service caused the Veteran’s disability but ‘whether the Veteran has a current disability that began during service’”); Bethea v. Derwinski, 2 Vet. App. 252, 254 (1992) (single judge decisions may be relied upon for any persuasiveness or reasoning they contain). Therefore, the March 2018 and June 2020 VA medical opinions do not weigh against the claim. The Board could remand the claim for another medical opinion, but a request for another opinion could be construed as obtaining additional evidence for the sole purpose of denying a claim, which is impermissible. 38 C.F.R. § 3.304(c) (“The development of evidence in connection with claims for service connection will be accomplished when deemed necessary but it should not be undertaken when evidence present is sufficient for this determination”); Gardner-Dickson v. Wilkie, No. 19-4765, 2020 U.S. App. Vet. Claims LEXIS 1927 (Panel Order), at *20 (denying petition for a writ of mandamus challenging a remand, but agreeing “with the petitioner that it ‘would not be permissible for VA to undertake... additional development if a purpose was to obtain evidence against an appellant’s case.’” (citing Mariano v. Principi, 17 Vet. App. 305, 312 (2003) and Hart v. Mansfield, 21 Vet. App. 505, 508 (2007)). The above evidence is sufficient to decide the claim, as it is approximately evenly balanced as to whether the current right lower extremity varicose veins had their onset in service. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for varicose veins, right lower extremity is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Buchanan, 451 F.3d at 1335 (lay evidence may be sufficient in and of itself to substantiate a service connection claim). Jonathan Hager Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. D. Simpson, 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.