Citation Nr: 21041436 Decision Date: 07/09/21 Archive Date: 07/09/21 DOCKET NO. 15-30 795 DATE: July 9, 2021 ORDER Entitlement to service connection for a left lower extremity disability is denied. FINDING OF FACT The evidence of record does not reflect any diagnosed, undiagnosed, or other qualifying left lower extremity disability during the period on appeal. CONCLUSION OF LAW The criteria for entitlement to service connection for a left lower extremity disability have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served in the Reserves from June 1978 to March 2017 with active duty from January 2004 to July 2005 and from July 2010 to August 2010. In addition, the Veteran completed periods of active duty for training (ACDUTRA) from June 1978 to April 2010. This case comes before the Board of Veterans' Appeals (Board) on appeal from a March 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Board notes that this matter has been advanced on the docket pursuant to 38 C.F.R. § 20.900(c). The appeal was last remanded by the Board in February 2021 for additional development. A review of the claims file shows that there has been substantial compliance with the Board's prior remand directives and thus, no further action in this regard is warranted. See Stegall v. West, 11 Vet. App. 268 (1998). Entitlement to a left lower extremity disability The Veteran's representative asserts that the Veteran has left lower extremity radiculopathy that is secondary to the Veteran's service-connected low back disability and service-connected right lower extremity radiculopathy. Factual Background An April 1978 report of medical history made at the time of the Veteran's enlistment noted that the Veteran had a prior operation on his left leg in November 1976 due to a fractured left femur. A December 2013 service treatment record notes that the Veteran reported back pain with a previous history of sciatica. The record does not mention whether the Veteran's left or right lower extremities were affected. A February 2014 private treatment record notes that the Veteran had a recent history of acute radiculopathy secondary to his low back disability with severe foraminal stenosis right worse than left. A June 2015 service treatment record notes that the Veteran had low back problems after a weekend drill doing sit-ups. The record also notes that the Veteran was very symptomatic with positive radiculopathy signs and significant decrease in range of motion. The record does not indicate which extremity evidenced radiculopathy. A June 2015 service treatment record notes that the Veteran had a lumbar disability with radiculopathy but did not specify whether one or both legs experienced radicular symptoms. A July 2015 service treatment record notes that the Veteran had low back pain since 2009 with increased severity since January 2014. The Veteran reported that the pain was constant and radiated down his right leg to his ankles with numbness too. Reflexes were normal throughout except for his right patellar reflex. A July 2015 service treatment record notes that no lower extremity weakness was observed. In an October 2015 statement in support of his claim the Veteran stated that he had right leg radiculopathy due to his low back disability but did not state any left leg complaints although he did mention that he was told that he would most likely not feel pain from injury due to "the consequences of losing sensation in my legs." November 2015 and February 2016 VA treatment records note that the Veteran had low back pain with radiculopathy but does not specify whether the radiculopathy was located in the left, right, or both lower extremities. A June 2016 VA treatment record notes that the Veteran complained of low back pain with radicular symptoms in the right lower extremity and also cramps on the left leg and numbness on the left foot. The Veteran reported that he had an EMG study performed on his right leg and was diagnosed with right lower extremity radiculopathy. No diagnosis of radiculopathy for the left leg was noted. A November 2018 private treatment record notes that the Veteran had persistent right lower extremity pain, numbness, and cramping. The record further notes that the Veteran referred to similar symptoms of the left lower extremity within the last year. The Veteran was afforded an in-person VA examination for his service-connected back disability in September 2020. The VA examiner's report notes that sensory examination was all normal for the Veteran's left upper anterior thigh, thigh/knee, lower leg/ankle, and foot/toes. Left knee and ankle deep tendon reflexes were normal. No radiculopathy was noted for the left side. And no constant pain, intermittent pain, paresthesias and/or dysesthesias or numbness was noted for the left lower extremity. The Veteran was afforded an in-person VA examination in March 2021. The VA examiner noted that the Veteran had a service-connected lower back disability that was manifested by frequent aching and burning pain, tingling, and numbness with occasional giving way of his right leg. The VA examiner noted that the Veteran had a diagnosis of right lower extremity radiculopathy for which the Veteran had been awarded service connection. The VA examiner noted that the Veteran was specifically asked about his left leg but that the Veteran denied having left lower extremity symptoms. The VA examiner noted that the Veteran did not have constant pain, intermittent pain, paresthesias and/or dysesthesias, or numbness in his left lower extremity. The Veteran retained 5/5 strength in his left leg with no muscle atrophy. The Veteran had normal deep tendon reflexes in both his left knee and left ankle. And, the Veteran had a normal gait. Evaluation revealed a normal sciatic nerve, external popliteal nerve, musculocutaneous nerve, anterior tibial deep nerve, internal popliteal nerve, posterior tibial nerve, anterior crural nerve, internal saphenous nerve, obturator nerve, external cutaneous nerve, and ilio-inguinal nerve on the Veteran's left side. The VA examiner determined that the Veteran's claimed left lower peripheral nerve condition or peripheral neuropathy did not impact his ability to work. The VA examiner concluded that the Veteran had no left lower extremity radicular complaints, left lower extremity complaints, nor evidence of left lower extremity radiculopathy. Analysis Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection generally requires evidence satisfying three criteria: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship ("nexus") between the current disability and the disease or injury incurred or aggravated during service. Walker v. Shinseki, 708 F.3d 1331, 1333 (Fed. Cir. 2013). Secondary service connection may be granted when a disability is proximately due to or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 447-48 (1995). Here, the Board finds that the Veteran does not have a left lower extremity disability. The Board emphasizes that service treatment records and post-service treatment records regularly note that the Veteran had right lower extremity radiculopathy. The Veteran has already been awarded service connection for right lower extremity radiculopathy. The question is whether the Veteran has left lower extremity radiculopathy warranting service connection, however, the evidence does not show that the Veteran had such a disability. The only references to left lower extremity symptoms are contained in the October 2015 statement in support of claim, the June 2016 VA treatment record, and the November 2018 private treatment record. In his October 2015 statement in support of his claim, the Veteran specifically referenced radiculopathy in his right leg before mentioning that he had consequences from losing sensation in his "legs". While the June 2016 VA treatment record again noted that the Veteran had radicular symptoms in his right lower extremity, the record only referenced left leg cramps and left foot numbness without any finding or diagnosis of radiculopathy. Lastly, the November 2018 private treatment record again noted that the Veteran had persistent right lower extremity symptoms with left lower extremity symptoms only reported within the last year. The Board emphasizes that even this favorable evidence failed to diagnose the Veteran with left lower extremity radiculopathy or any other disability. Furthermore, the Board affords greater probative value to the September 2020 and March 2021 VA examinations which found against any left lower extremity disability. The Board emphasizes that when specifically asked about his left lower extremity during the March 2021 VA examination, the Veteran denied having any symptoms. The affords great probative value to the Veteran's admission that he did not have any symptoms. This is consistent with the findings during both VA examinations which found against any left lower extremity symptoms or disability. As previously mentioned, the first prong of a service connection claim is a current disability. The evidence does not demonstrate that the Veteran had a left lower extremity disability during the pendency of the appeal. The U.S. Court of Appeals for Veterans Claims has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Thus, the Board must deny the claim. Accordingly, the Veteran's claim for entitlement to service connection for a left lower extremity disability must be denied due to the absence of a disability during the period on appeal. KELLI A. KORDICH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Palombi 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.