Citation Nr: 21027325 Decision Date: 05/05/21 Archive Date: 05/05/21 DOCKET NO. 15-33 713 DATE: May 5, 2021 ORDER Entitlement to service connection for right leg venous stasis secondary to type 2 diabetes mellitus (DMII), on a causation basis, is granted. FINDING OF FACT The evidence is at least evenly balanced as to whether the Veteran's right leg venous stasis was caused by his service connected DMII. CONCLUSION OF LAW With reasonable doubt resolved in favor of the Veteran, the criteria for entitlement to service connection for right leg venous stasis secondary to service connected DMII, on a causation basis, have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from June 1967 to May 1975. This case comes before the Board of Veterans' Appeals (Board) on appeal of a December 2014 rating decision by the Department of Veterans Affairs (VA) RO in Philadelphia, Pennsylvania which, inter alia, denied reopening service connection claims for poor circulation secondary to DMII. In March 2015 the Veteran filed his notice of disagreement, and in August 2015 was issued a statement of the case and perfected his appeal to the Board. In May 2019 the Veteran appeared at a videoconference Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. In May 2019, the Board reopened and remanded the Veteran's claim for a medical opinion regarding whether the Veteran's poor circulation was caused or aggravated by his DMII. Service Connection 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). Service connection is also warranted for disability proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (b). Poor Right Leg Circulation The Veteran contends that he suffers from poor right leg circulation due to his service connected DMII. A December 2006 physician's letter indicates that the Veteran reported that he recently had an ulcer on his right heel which became infected and resulted in an amputation of his toes on his right foot. January 2007 medical treatment records from the Social Security Administration (SSA) reflects that the Veteran had a history of right first metatarsophalangeal ulcer with abscess, right second metatarsal osteomyelitis with nonhealing ulcer, and right third metatarsal ulcer with osteo. May 2008 private treatment records reflect that the Veteran has normal arterial blood flow to the level of both forefeet, including adequate blood flow for healing of a right foot wound. A June 2008 private physician's letter indicated that the Veteran has developed an area of ulceration on his calcaneus with exposure of the bone. The physician reported that the Veteran underwent a lower extremity arterial pulmonary vascular resistance (PVR) study with findings of excellent pulse volume recording tracings all the way down to the metatarsal level bilaterally. The physician noted that the Veteran did not have a major vascular obstruction leading to significant vascular insufficiency to his foot, stating that Veteran's problem centers around "the ravages of his diabetes." December 2008 VA post-service treatment notes indicate the Veteran reported that he was told by his physician that he suffered from poor circulation of the legs which he stated was confirmed by vascular tests. In a June 2019 VA examination report, the examining physician's assistant (PA) explained that the June 2008 vascular surgeon's note intended to convey that the Veteran's below knee amputation (BKA) on the right was not a circulation issue, but rather a combination of other complications from the diabetes, including his diabetes peripheral neuropathy and ongoing foot ulcers that eventually led to osteomyelitis, which led to his BKA. The PA explained that "poor circulation" has to do with arterial blood flow, and noted that the ankle brachial index (ABI) prior to the Veteran's amputation was normal, thus he had good circulation. The examination report reflected a diagnosis of peripheral vascular disease, but the PA noted that the Veteran had not had an amputation of an extremity due to a vascular condition. The PA emphasized that the BKA was not done due to "poor circulation" or any arterial issues at the time, but rather due to other complications of diabetes including neuropathy and poor healing capability which led to osteomyelitis and the need for the BKA. In a July 2019 letter, the Veteran's private physician stated that the Veteran is a type 2 insulin dependent diabetic with consequential severe peripheral neuropathy. He also stated that another of the Veteran's diabetic manifestations is chronic venous stasis which when coupled with progressive arterial sclerotic vascular disease predisposes him to infection and the increased risk of further limb loss, noting that the Veteran has already had an above the knee amputation of the right leg. In a January 2020 VA examination report, the PA opined that the Veteran's right leg amputation was at least as likely as not (at least a 50 percent probability) due to, or a result of the Veteran's service connected DMII. The PA noted that previous VA examination reports document that the right lower extremity amputation is more than likely due to microvascular disease that is consistent with long term, poorly controlled DMII. Therefore, the amputations would most likely be secondary to his DMII. In a February 2020 addendum opinion, the PA stated that prior to his right leg BKA, the Veteran's ABI showed good arterial circulation and the reason for the right BKA was due to complications from DMII including osteomyelitis (infection) from diabetic ulcers. For the following reasons, the Board finds that entitlement to service connection for the Veteran's poor right leg circulation is warranted. The Veteran stated that he was informed by his physician that he suffered from poor circulation of the legs, and the Veteran is competent to relate what has been told to him by a physician. See Jandreau v. Nicholson, 492 F. 3d 1372, 1377, n.4 (Fed. Cir. 2007). While the June 2019 PA explained that the note regarding the right leg BKA was not a circulation issue, reported that the Veteran had good circulation prior to his BKA, and clarified that the right BKA was the result of DMII complications, the July 2019 private physician opined that the Veteran's chronic venous stasis coupled with progressive arterial sclerotic vascular disease predisposes him to infection and the increased risk of further limb loss, implying that such manifestations contributed to his right limb amputation. The July 2019 private physician provided a thorough rationale as to the contributing factors of the Veteran's right limb amputation based on an accurate characterization of the evidence of record, thus his opinion is afforded significant probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). There are both positive and negative medical nexus opinions of record which are afforded significant probative weight. The evidence is thus at least evenly balanced as to whether the Veteran's right leg venous stasis which resulted in his right leg amputation was caused by his service connected DMII. 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 right leg venous stasis secondary to DMII, on a causation basis, is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Jonathan Hager Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Maddox, 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.