Citation Nr: 21042043 Decision Date: 07/11/21 Archive Date: 07/11/21 DOCKET NO. 10-18 175 DATE: July 11, 2021 ORDER Entitlement to service connection for a depressive disorder as secondary to posttraumatic stress disorder (PTSD) is granted. REMANDED Entitlement to service connection for chronic edema is remanded. Entitlement to service connection for a disability manifested by numbness, tingling, and pain in the toes of the left foot is remanded. Entitlement to service connection for left leg neuropathy is remanded. FINDING OF FACT Resolving reasonable doubt in the Veteran's favor, a depressive disorder is proximately due to his service-connected PTSD. CONCLUSION OF LAW The criteria for service connection for a depressive disorder as secondary to service-connected PTSD have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active military service from March 1968 to March 1970 with service in Vietnam from March 1969 to March 1970. This matter is before the Board of Veterans' Appeals (Board) following Board Remands in September 2016 and May 2018. 1. Entitlement to service connection for depression as secondary to PTSD The Veteran contends that he has a depressive disorder secondary to PTSD. Service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury pursuant to 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show that a current disability exists and that the current disability was either caused by or aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). The Veteran underwent VA psychiatric examination in January 2010 at which time he described having depression and anxiety and worry about financial issues; he was diagnosed as having PTSD. VA treatment records indicate that the Veteran was assessed as having depressive disorder NOS, PTSD, and depression. The Veteran underwent VA PTSD examination in May 2019 at which time he was diagnosed as having PTSD and major depressive disorder (MDD). The examiner noted that MDD was related to the multiple losses and deaths in the prior 10 years and not related to military service. The Veteran underwent VA examination in November 2020 at which time the examiner noted that the Veteran met the criteria for depressed mood secondary to PTSD. The examiner noted that depressed mood secondary to PTSD was documented in VAMC treatment records in March 2010 and was present at time of evaluation. The examiner noted that the Veteran's depression secondary to PTSD was due to lack of treatment for PTSD and barrier to accessing care due to paranoid ideation secondary to trauma-related illness. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran's current depressive disorder is proximately due to service-connected PTSD. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for depression is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 2. Entitlement to service connection for chronic edema The service treatment records are absent complaints, findings or diagnoses of edema during service. On the clinical examination for separation from service, the Veteran's spine, lower extremities, and feet were evaluated as normal. Further, on the Report of Medical History completed by the Veteran in conjunction with his separation physical, he denied ever having swollen joints, back trouble of any kind, and foot trouble. Private treatment records indicate edema in December 2005 and trace edema/stasis dermatitis in February 2006. On his application for compensation received in December 2007, the Veteran reported that his chronic edema began in 2002 and that he began treatment in 2004. In September 2009, the Veteran testified before a Decision Review Officer that he experienced edema of his feet, his right hip, and his lumbar spine. The Veteran underwent VA diabetes mellitus examination in January 2010 at which time he was noted to have +1 peripheral edema. The Veteran underwent VA examinations in May 2019 at which time the examiner noted that he denied having issues concerning edema of the back or legs and denied issues with his left toes. The Veteran underwent VA peripheral nerves conditions examination in July 2019 at which time physical examination demonstrated pain and swelling of right foot which the examiner attributed to pes planus. A medical opinion regarding the Veteran's claimed edema was obtained in October 2020. The examiner opined that the Veteran's claimed chronic edema was less likely than not incurred in or caused by service injury, event, or illness; proximately due to service-connected condition; and aggravated beyond its natural progression by the veteran's service-connected condition. The examiner noted that exposure to herbicides and diabetes did not cause chronic edema of right hip and low back and that there was no medical literature which showed a connection where diabetes caused edema or the foot disability/foot problems. Unfortunately, the October 2020 opinion is flawed. In addition to the opinion being conclusory, pertinent evidence was not addressed. In this case, +1 peripheral edema was noted in January 2010 and the absence of hair on the Veteran's feet and legs was noted on VA examination in July 2019. Neither was addressed in the October 2020 opinion. As such, the Board finds that an additional examination and addendum opinion is necessary. 3. Entitlement to service connection for a disability manifested by numbing, tingling and pain in the toes of the left foot 4. Entitlement to service connection for left leg neuropathy On his application for compensation received in December 2007, the Veteran reported that his left toe numbing, tingling, and pain as well as left leg neuropathy began in 1987 and that he began treatment in 1997. In September 2009, the Veteran testified before a Decision Review Officer that he experienced numbness, tingling, and discoloration in his feet for 30 to 40 years. The Veteran underwent VA diabetes mellitus examination in January 2010 at which time he denied any symptoms relative to peripheral neuropathy in a stocking and glove-type distribution, and sensory examination was intact. The Veteran underwent VA thoracolumbar spine conditions examination in September 2012 at which time he was noted to have been diagnosed with back strain in 1970 secondary to a fall in the shower. The examiner found no radicular pain or any other signs or symptoms due to radiculopathy. The Veteran underwent VA examination in May 2019 at which time the examiner noted that he had no issues with left foot or left toes. In addition, he was noted to have been diagnosed with lumbosacral strain in 1969. Reflex and sensory examinations were normal; straight leg raising was negative; the examiner found no radicular pain or any other signs or symptoms due to radiculopathy. The examiner also found that there was no neuropathy of the left leg. The Veteran underwent VA Peripheral Nerve Conditions examination in July 2019 at which time he reported pain radiating from hips to lower extremities and numbness and tingling of lower extremities for 50 years. The examiner noted that the Veteran reported moderate right lower extremity and mild left lower extremity symptoms including constant and intermittent pain, paresthesias and/or dysesthesias, and numbness. Muscle strength testing was normal; reflex examination demonstrated absent deep tendon reflexes in the knees and ankles; and sensory examination showed decreased sensation in the lower legs/ankles (L4/L5/S1) and feet/toes (L5). The Veteran also had no hair on his feet and legs. The Veteran was noted to have moderate incomplete paralysis of the right sciatic nerve and mild incomplete paralysis of the left sciatic nerve. The Veteran was diagnosed as having bilateral sciatic nerve paresis. The Veteran underwent VA Peripheral Nerve and Thoracolumbar Spine examinations in October 2020 at which time he reported that left leg pain, numbness and tingling began in 2000. The examiner noted that the Veteran reported moderate left lower extremity intermittent pain, paresthesias and/or dysesthesias, and numbness. On physical examination, muscle strength testing was slightly diminished on knee and ankle motion; reflex and sensory examinations were normal. The examiner found that the Veteran had moderate incomplete paralysis of the sciatic nerve. The examiner indicated that the Veteran did not have a peripheral nerve condition and/or peripheral neuropathy and noted that the condition found on examination was radiculopathy due to the back. He was diagnosed as having left lower extremity radiculopathy (sciatic nerve) due to lumbosacral strain. The examiner opined that the Veteran's numbness and tingling of his left foot toes were less likely than not incurred in or caused by service injury, event, or illness; proximately due to service-connected condition; and aggravated beyond its natural progression by the veteran's service-connected condition. The examiner noted that exposure to herbicides did not cause numbness and tingling of left foot toes, that numbness and tingling of the left foot toes were related to radiculopathy, and that there was no evidence of diabetes aggravating the condition. The examiner also opined that the Veteran's left leg neuropathy was less likely than not incurred in or caused by service injury, event, or illness; proximately due to service-connected condition; and aggravated beyond its natural progression by the veteran's service-connected condition. The examiner noted that exposure to herbicides did not cause left leg neuropathy, that there was no medical literature which showed a connection where PTSD caused left leg neuropathy, and that left leg neuropathy was related to radiculopathy, and that there was no evidence of diabetes aggravating the condition. Unfortunately, the October 2020 opinion is flawed. In addition to the fact that the opinion is conclusory, at the July 2019 VA examination, reflex examination showed absent reflexes in the knee and ankle and sensory examination demonstrated decreased sensation in lower leg/ankle, feet/toes. The symptoms reported in the July 2019 VA examination were not addressed in the October 2020 opinion. As such, the Board finds that an additional examination and addendum opinion is necessary. The matters are REMANDED for the following action: 1. Ask the Veteran to identify all VA treatment and/or private treatment for diabetes mellitus, edema, and neuropathy of the left lower extremity. Ask the Veteran to complete a VA Form 21-4142 for all private physicians/facilities which have treated him for diabetes mellitus, edema, and neuropathy of the left lower extremity since January 2016. Make two requests for the authorized records unless it is clear after the first request that a second request would be futile. 2. Schedule the Veteran for a VA examination(s) by an appropriate clinician(s) to provide an opinion concerning edema and neuropathy of the left lower extremity. After a thorough review of the claims file, the examiner is asked to provide a response to the following: (a) Identify all disabilities manifested by edema, to include any vascular disease, that have been present since December 2007. In so doing, the examiner should acknowledge and consider the finding of +1 peripheral edema noted in January 2010 and the absence of hair on the Veteran's feet and legs noted on VA examination in July 2019. (b) Identify all disabilities manifested by neuropathy of the left lower extremity; and numbness, tingling, and pain in the toes of the left foot that have been present since December 2007. In so doing, the examiner should acknowledge and consider the July 2019 VA examination report showing absent reflexes in the knee and ankle and decreased sensation in lower leg/ankle, feet/toes. (c) For any disabilities manifested by edema, to include any peripheral vascular/arterial disease, is it at least as likely as not (50% or greater probability): (i) related to in-service exposure to herbicide agents; (ii) proximately due to service-connected hypertension, type II diabetes mellitus, and/or bilateral pes planus with right foot callus; or (iii) worsened beyond its natural progression by service-connected hypertension, type II diabetes mellitus, and/or bilateral pes planus with right foot callus? (c) For any disabilities manifested by neuropathy of the left lower extremity, and/or numbness, tingling, and pain in the toes of the left foot, is it at least as likely as not (50% or greater probability): (i) related to in-service exposure to herbicide agents; (ii) proximately due to service-connected type II diabetes mellitus and/or bilateral pes planus with right foot callus; or (iii) worsened beyond its natural progression by service-connected type II diabetes mellitus and/or bilateral pes planus with right foot callus? (Continued on the next page) A complete rationale should be provided. P.M. DILORENZO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Olson, Patricia 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.