Citation Nr: 21032292 Decision Date: 05/26/21 Archive Date: 05/26/21 DOCKET NO. 16-14 773 DATE: May 26, 2021 REMANDED Entitlement to service connection for reflex sympathetic dystrophy (RSD), recharacterized as peripheral neuropathy left foot is remanded. Entitlement to service connection for reflex sympathetic dystrophy (RSD), recharacterized as peripheral neuropathy right foot is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1999 to February 2002. This case initially came before the Board of Veteran's Appeals (Board) on appeal from an August 2015 rating decision of the Department of Veterans (VA) Regional Office (RO) in Waco, Texas. These matters were previously remanded by the Board for additional development in a September 2018 decision and again in a November 2019 decision. Unfortunately, the Board finds that the evidence of record is insufficient to decide the claims on appeal and an adequate medical examination is necessary before a decision can be reached on the merits. The Board is obligated by law to ensure that the RO complies with its directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). RO compliance with remand directives is not optional or discretionary, and the Board errs as a matter of law when it fails to ensure remand compliance. Stegall, 11 Vet. App. at 271. Accordingly, remand is required to obtain an adequate medical opinion that complies with the Board remand directives. 1. Entitlement to service connection for reflex sympathetic dystrophy (RSD), recharacterized as peripheral neuropathy left foot. 2. Entitlement to service connection for reflex sympathetic dystrophy (RSD), recharacterized as peripheral neuropathy right foot. The Veteran contends that service connection for reflex sympathetic dystrophy (RSD), recharacterized as peripheral neuropathy right and left foot is warranted because it was caused in-service. The Veteran also asserts that she has lost her mobility and indicates that the RSD is beginning to take on her hands and arms and that she has struggled with the extremely painful condition for over 13 years. See Notice of Disagreement Received August 2015. The Veteran also asserts that the injuries that she incurred began in basic training and still exist to date. See Lay Statement Received July 2019. The Board notes that the Veteran is currently service connected for residuals of hypoplastic lymphatics of the right foot and scarring of the right lower extremity associated with residuals of hypoplastic lymphatics of the right foot. See Rating Decision Dated November 2020. Every veteran is presumed to have been in sound condition at entry into service except as to defects, infirmities, or disorders noted at the time of such entry, or where clear and unmistakable evidence demonstrates that the injury or disease existed before entry and was not aggravated by such service. 38 U.S.C. § 1111. If a condition is noted on an entrance examination report, the presumption of soundness never attaches - the only benefits that can be awarded are for aggravation of such condition by application of 38 U.S.C. § 1153 and 38 C.F.R. § 3.306. Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). The burden falls on the veteran to establish aggravation. Jensen v. Brown, 19 F.3d 1413, 1417 (Fed. Cir. 1994). For service connection claims involving a preexisting injury or disease, 38 U.S.C. § 1153 provides that a preexisting injury or disease will be considered to have been aggravated by service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 C.F.R. § 3.306(a). Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during and subsequent to service. 38 C.F.R. § 3.306(b). In this case abnormalities of the Veteran's feet were noted at entry, but it remains unclear whether the Veteran's current diagnosed bilateral lower extremity disabilities are a manifestation of the abnormalities initially noted in service. The Veteran's service treatment records indicate that the Veteran experienced foot issues prior to and during service. The Veteran's enlistment examination dated August 1999 indicates that the Veteran's feet were abnormal and it was also noted that the Veteran had bilateral hallux valgus. An August 2001 treatment record states that the Veteran experienced unilateral foot swelling, post pregnancy in a patient (the Veteran) who otherwise had general good appearance of health. Another August 2001 service treatment note states that the Veteran experienced right foot swelling up to the medial ulnus of the ankle with loss of wrinkles on her right as well as chubby, swollen toes and the foot between these two points. Additionally, it is noted that there is no undue varicosities in either of her ankles. A December 2001 service treatment record states that the Veteran has presumptive absence of lymphatic vessels in the lower extremities which is causing swelling and pain and preventing her from maintaining her weight, meeting PRT requirements, and performing her assigned duties. The Veteran's post service treatment notes include several complaints of foot pain, swelling, and edema. The Board notes that the Veteran's mother (RC) submitted a lay statement that was received by the Board in July 2019. The Veteran's mother, RC stated that the Veteran was not born with lymphedema or swelling of her feet or legs at birth. RC further noted that the Veteran was a healthy baby girl and she never had any problems with her feet or legs until she went to the Navy. RC also stated that during intense bootcamp training in 1999 is when the Veteran started having issues which caused the injuries that she has been suffering from. RC also stated that the Veteran was on crutches for a period of time while in boot camp, due to her injuries. The Veteran was afforded several VA examinations to assess her bilateral foot disability. The Veteran was afforded a Disability Benefits Questionnaire examination in July 2015. The examiner diagnosed her with lymphedema of the bilateral lower extremities. The examiner noted that there was no objective evidence supporting a diagnosis of hypoplastic lymphatics of the left foot. In the medical history section of the examination report, the examiner noted that the Veteran reported that she began to experience swelling in her right foot about two months after entering the military. It is also noted that there is no known history of trauma. Additionally, it is noted that the Veteran underwent a Lymphangiogram which was unsuccessful due to not being able to adequately demonstrate lymphatics in the Veteran. It is further noted that the Veteran was subsequently diagnosed with possible Milroy's disease, meaning that the Veteran had either hypoplastic or absent lymphatics. The examiner noted that since visiting the Lymphedema clinic, the Veteran experienced swelling involving the right foot and most recently the left foot had worsened. The examiner also stated that the Veteran has tried compression hose and elevation of her extremities without significant improvement. The examiner noted that the Veteran did not currently have any conditions, complications and/or residuals due to a hematologic or lymphatic disorder or due to treatment for a hematologic or lymphatic disorder. In a peripheral neuropathy Disability Benefits Questionnaire in July 2015, the examiner diagnosed the Veteran with neuropathy of the hands and feet. The examiner noted that the claimed reflex sympathetic dystrophy (RSD) condition had not been established or definitively confirmed in the Veteran. It is also noted that the Veteran reported that she is experiencing numbness and burning sensations of the bilateral extremities which started in 2004. It is noted that the Veteran attributes her symptoms to having lymphedema and RSD. It is also noted that the Veteran experienced severe peripheral nerve conditions of constant pain, paresthesias and/or dysesthesias, and numbness in her right and left lower extremities. Medical opinions dated July 2015 of record provide etiological opinions related to the Veteran's bilateral foot condition. The examiner stated that the Veteran's claimed hypoplastic lymphatics of the left foot is less likely than not proximately due to or the result of the Veteran's service- connected residuals of hypoplastic lymphatics of the right foot. As rationale, the examiner stated that there is insufficient evidence to support the Veteran's claim and there is a lack of evidence in the medical literature to support the Veteran's claim. Furthermore, the examiner stated that medically there has not been shown to be a causal relationship between hypoplastic lymphatics of the left and right foot. The examiner stated that according to the records, RSD has not been established or definitively confirmed in the Veteran and further there is insufficient evidence and a lack of medical literature and documentation to support the Veteran's claim. In the July 2015 etiological opinion, the examiner opined that the Veteran's bilateral RSD was not etiologically related to service, but did not opine as to whether the diagnosed bilateral neuropathy was caused or aggravated by service. As such, the matter was remanded for further development on that specific issue. The Veteran was afforded a VA contract examination in May 2019. While the May 2019 VA contract examiner opined that the Veteran's bilateral neuropathy was not caused as a result of service, the examiner did not provide an opinion on whether the condition was aggravated as a result of service. See May 2019 VA examination. Furthermore, while the right foot swelling noted on the entrance examination was discussed per the Board's previous remand directive, the examiner did not indicate whether the claimed condition clearly and unmistakably existed prior to service and was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. Therefore, the May 2019 examination was deemed inadequate. The Veteran was afforded another examination in December 2019. The examiner stated that review of the STRs show the Veteran's entrance history and notes swelling foot, hypoplastic lymphatics right lower extremity (RLE). Additionally, the examiner stated that further evaluation diagnosed hypoplastic RLE lymphatics, Milroy's disease. The examiner explained that this is a genetic defect which clearly preexisted military service. Additionally, the examiner stated that there is no evidence that hypoplastic lymphatics was permanently aggravated beyond its natural progression by military service. The examiner explained that Milroy's disease is a familial disease characterized by lymphedema, commonly in the legs, caused by congenital abnormalities in the lymphatic system. The examiner further explained that disruption of the normal drainage of lymph leads to fluid accumulation and hypertrophy of soft tissues. The examiner stated that the most common presentation of Milroy Disease is unilateral lower extremity lymphedema and the disease is more common in women and an association with the gene FLT 4 has been described. Moreover, the examiner stated that reflex sympathetic dystrophy can result from chronic lower extremity swelling and is considered a natural progression of the condition. The examiner stated that reflex sympathetic dystrophy syndrome, also known as complex regional pain syndrome is a rare disorder of the sympathetic nervous system that is characterized by chronic, severe pain. The examiner also stated that pain and swelling associated with reflex sympathetic dystrophy syndrome may occur at the site of a previous injury, surgery, trauma, or radiation therapy. The examiner also stated that pain may extend beyond the original area of the injury and is more severe than the original trauma. Lastly, the examiner stated that eventually, the entire limb may become involved and, in some cases, symptoms can spread to other areas of the body. The Board finds that the most recent December 2019 examination is inadequate, contradictory, and unclear. The examiner failed to clarify exactly what bilateral lower extremity disabilities the Veteran had during the appeal period. Although the examiner explained the definition of Milroy's disease and reflex sympathetic dystrophy, he provided no basis for characterizing the Veteran's bilateral lower level extremity symptoms as genetic as opposed to symptoms that were incurred in or aggravated by service. It is difficult to make sense of this medical opinion in light of the statement provided by the Veteran's mother RC who stated that the Veteran was not born with any abnormalities in her legs and feet. Moreover, the Board takes issue with the examiner's assessment that the Veteran's bilateral lower level extremity disorder pre-existed service and his reference to the entrance history note that states "RLE swelling foot, hypoplastic lymphatics RLE" and his statement that there is no evidence hypoplastic lymphatics was permanently aggravated beyond its natural progression by military service. The Board finds that these statements are conflicting because the Veteran is, in fact, service connected for residuals of hypoplastic lymphatics of the right foot and scarring of the right lower extremity associated with residuals of hypoplastic lymphatics of the right foot. Given the examiner's statements and conclusion that the disability was not aggravated beyond its natural progression by military service, the Board is not confident the examiner understood the Veteran is service-connected for residuals of hypoplastic lymphatics of the right foot. Furthermore, the Board finds that the December 2019 opinion is not responsive to determining whether the Veteran did, in fact, have a bilateral lower extremity disability that pre-existed service nor is it responsive to determining whether or not service connection is warranted on a direct or secondary basis for a bilateral lower extremity disability. Remand is required for a new VA examination and opinion. The Board is obligated by law to ensure that the RO complies with its directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). RO compliance with remand directives is not optional or discretionary and the Board errs as a matter of law when it fails to ensure remand compliance. Stegall, 11 Vet. App. at 271. Where VA provides the Veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). A medical opinion must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). As all of the current examinations of record have been deemed inadequate, remand is required. These matters are REMANDED for the following action: 1. Obtain updated VA and non-VA treatment records. 2. Schedule the Veteran for a VA examination by an examiner with appropriate expertise, preferably by one who has not previously examined the Veteran in connection with this appeal, to determine the etiology of the Veteran's claimed bilateral lower extremity disabilities. The examiner must review this remand and the record to include all prior examinations in their entirety. The examiner should note review of all of the evidence of record in the report. A rationale for all opinions must be provided. The examiner should provide responses to the following directives: a. Identify all lower bilateral extremity disabilities by either (a) diagnosis or (b) functional impairment that the Veteran had during the period on appeal. The examiner must address whether the Veteran has peripheral neuropathy; reflex sympathetic dystrophy syndrome; radiculopathy; and/or pain. The examiner should clarify whether each identified diagnosis is separate and distinct from the Veteran's service-connected hypoplastic lymphatics right foot residuals disease and her service-connected scarring of the right lower extremity residuals disorders. b. As to each lower extremity disability identified, please state whether it clearly and unmistakably (undebatable) pre-existed service. In doing, so, the examiner should consider and address the notations on the Veteran's enlistment examination dated August 1999 indicating that the Veteran's feet were abnormal and that the Veteran had bilateral hallux valgus. The examiner must also consider and address the statement provided by the Veteran's mother, RC, that the Veteran was not born with lymphedema or swelling of her feet or legs at birth and instead developed bilateral lower extremity issues while in the military in 1999. c. If the examiner finds it did clearly and unmistakably preexist service, the examiner must then opine whether the lower extremity disability was clearly and unmistakably (undebatable) NOT aggravated beyond the natural progression of the condition by active service. In doing so, the examiner must consider and address the following: an August 2001 treatment record states that the Veteran experienced unilateral foot swelling, post pregnancy in a patient (the Veteran) who otherwise had general good appearance of health; another August 2001 service treatment note states that the Veteran experienced right foot swelling up to the medial ulnus of the ankle with loss of wrinkles on her right as well as chubby, swollen toes and the foot between these two points, as well as no undue varicosities in either of her ankles; a December 2001 service treatment record states that the Veteran has presumptive absence of lymphatic vessels in the lower extremities which is causing swelling and pain and preventing her from maintaining her weight, meeting PRT requirements, and performing her assigned duties. d. If the examiner finds that the Veteran's lower extremity condition either (1) did not clearly and unmistakably preexist service or (2) was clearly and unmistakably NOT aggravated beyond the natural progression of the condition, the examiner must opine whether it at least as likely as not (50 percent or greater probability) that the disability had its onset in service or is otherwise the result of a disease or injury in service? e. If the examiner finds that the Veteran's lower extremity condition either (1) did not clearly and unmistakably preexist service or (2) was not clearly and unmistakably due to the natural progression of the condition, the examiner must opine whether it at least as likely as not (50 percent or greater probability) that the disability was caused by the Veteran's service-connected hypoplastic lymphatics right foot residuals disease or her service-connected scarring of the right lower extremity residuals disorder. f. If the examiner finds that the Veteran's lower extremity condition either (1) did not clearly and unmistakably preexist service or (2) was not clearly and unmistakably due to the natural progression of the condition, the examiner must opine whether it at least as likely as not (50 percent or greater probability) that the disability was aggravated by the Veteran's service-connected hypoplastic lymphatics right foot residuals disease or her service-connected scarring of the right lower extremity residuals disorder. The examiner is advised that causation and aggravation are separate questions, and therefore both theories must be addressed in the opinion. A complete rationale must be provided for each opinion offered. The examiner must consider the lay statements of record. If the examiner is unable to provide a medical opinion, then he/she should must explain in detail why that is the case and provide a statement as to whether there is any additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. Tiffany Dawson Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Dorsey-Kwansa, 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.