RESTLESS LEGS SYNDROME

Summary

The veteran, a Marine Corps veteran who served from August 1993 to October 1997, appeals the denial of service connection for restless legs syndrome (RLS) claimed as secondary to his service-connected PTSD with panic disorder, degenerative arthritis of the lumbosacral spine (previously rated as low back strain), and right lower extremity radiculopathy with orchialgia. The Board reviewed evidence including VA treatment records, VA examinations, and private medical opinions. A February 2021 VA examiner opined RLS was less likely than not related to service, citing a lack of objective evidence for a current diagnosis, but failed to address the Veteran's treatment history. A June 2021 private opinion from MD J.S. found PTSD significantly contributing to RLS but lacked sufficient explanation. A July 2021 VA examiner also found RLS less likely than not due to PTSD, citing general medical literature and a lack of direct causation, but failed to address potential medication aggravation. However, a May 2023 private medical opinion from PA-C P.R.D. persuasively linked RLS to the Veteran's service-connected conditions and medications, citing relevant studies on lumbar radiculopathy, SSRIs/SNRIs, and RLS. The Board found this private opinion more persuasive than the others, concluding that the evidence establishes RLS is caused by the Veteran's service-connected disabilities. Therefore, service connection for restless legs syndrome as secondary to his service-connected conditions was granted.

Rationale

Persuasive private medical opinion linking RLS to service-connected conditions and medications.; VA opinions found inadequate for failing to address treatment history or medication effects.; Evidence establishes RLS is caused by service-connected PTSD, arthritis, and radiculopathy.

Full Decision Text

Citation Nr: A26038593
Decision Date: 04/24/26	Archive Date: 04/24/26

DOCKET NO. 210722-174019
DATE: April 24, 2026

ORDER

Entitlement to service connection for restless legs syndrome, as secondary to service-connected posttraumatic stress disorder (PTSD) with panic disorder, degenerative arthritis, lumbosacral spine (previously rated as low back strain), and right lower extremity radiculopathy with orchialgia, is granted.

FINDING OF FACT

The Veteran's restless legs syndrome is caused by his service-connected PTSD with panic disorder, degenerative arthritis, lumbosacral spine (previously rated as low back strain), and right lower extremity radiculopathy with orchialgia.

CONCLUSION OF LAW

The criteria to establish service connection for restless legs syndrome, as secondary to service-connected PTSD with panic disorder, degenerative arthritis, lumbosacral spine (previously rated as low back strain), and right lower extremity radiculopathy with orchialgia, have been met. 38 U.S.C. § 1110; 38 C.F.R. § 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty in the United States Marine Corps from August 1993 to October 1997.  

This matter comes before the Board of Veterans' Appeals (Board) on appeal of a July 2021 rating decision of a Department of Veterans Affairs (VA) agency of original jurisdiction (AOJ). 

In the July 2021 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Hearing docket. A Board hearing was held on March 15, 2023.

Therefore, the Board may only consider the evidence of record at the time of the July 2021 AOJ decision on appeal, as well as any evidence submitted by the Veteran or his representative at the hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a). If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the Board hearing, or (2) more than 90 days following the hearing, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.302(a), 20.801. 

Entitlement to service connection for restless legs syndrome.

The Veterans seeks service connection for restless legs syndrome, as secondary to his service-connected PTSD with panic disorder, degenerative arthritis, lumbosacral spine (previously rated as low back strain), and right lower extremity radiculopathy with orchialgia. See, e.g., Board Hearing Transcript, March 2023; VA Form 21-4138, May 2023. For the reasons described below, the Board finds that entitlement to secondary service connection is established. 

Service connection generally will be awarded when a veteran has a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, 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 may also be established on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury; or, for any increase in the severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury. See 38 C.F.R. § 3.310(a)-(b); Allen v. Brown, 7 Vet. App. 439 (1995). To prevail under a theory of secondary service connection, there must be: (1) evidence of a current disorder; (2) evidence of a service-connected disability; and (3) medical evidence establishing a connection between the service-connected disability and the current disorder. See id. There is no requirement that the primary disability be the sole cause of the secondary disability. See Spicer v. McDonough, 61 F.4th 1360, 1364 (Fed. Cir. 2023) ("The but-for causation standard is not limited to a single cause and effect, but rather contemplates multi-causal links, including action and inaction..."). 

The determination as to whether these elements are met is based on an analysis of all evidence of record and an evaluation of its credibility and probative value. See Jones v. Principi, 16 Vet.
 evidence of a service-connected disability; and (3) medical evidence establishing a connection between the service-connected disability and the current disorder. See id. There is no requirement that the primary disability be the sole cause of the secondary disability. See Spicer v. McDonough, 61 F.4th 1360, 1364 (Fed. Cir. 2023) ("The but-for causation standard is not limited to a single cause and effect, but rather contemplates multi-causal links, including action and inaction..."). 

The determination as to whether these elements are met is based on an analysis of all evidence of record and an evaluation of its credibility and probative value. See Jones v. Principi, 16 Vet. App. 219, 225 (2002). The Board is required to consider all pertinent medical and lay evidence when evaluating a claim for disability benefits. 38 U.S.C. § 1154(a); see also Washington v. Nicholson, 19 Vet. App. 362, 367-68 (2005) (holding that the Board must assess the credibility of and weight to be given to the evidence).

Competent lay evidence is any kind of evidence that does not require that the proponent have specialized education, training, or experience. 38 C.F.R. § 3.159(a)(2). Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. See Layno v. Brown, 6 Vet. App. 465, 469-71 (1994).

Competent medical evidence is necessary where the determinative question is one that requires medical knowledge. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Competent medical evidence is provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. See Cox v. Nicholson, 20 Vet. App. 563, 569 (2007); 38 C.F.R. § 3.159(a)(1). It may also include sound medical principles found in medical 

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treatises and statements contained in authoritative writings such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). 

Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. However, when the evidence persuasively favors one side or the other, the evidence is not in approximate balance and the benefit-of-the-doubt rule does not apply. See Lynch v. McDonough, 21 F.4th 776, 781-82 (Fed. Cir. 2021).

As for a current disability, medical evidence of record reflects that the Veteran has been diagnosed with restless legs syndrome. See, e.g., Manchester VA Treatment Records, July 2015, September 2015; Medical Opinion, MD J.S., June 2021. As such, the Board finds the first element to establish service connection is met. 

The record also establishes that the Veteran is service connected for disabilities including PTSD with panic disorder, degenerative arthritis, lumbosacral spine (previously rated as low back strain), and right lower extremity radiculopathy with orchialgia. See, e.g., Rating Decision, Code Sheet, April 2024. As such, the second element to establish secondary service connection is met. 

The remaining question is whether the evidence of record establishes that the Veteran's current disability is caused by or aggravated by a service-connected disability. The Board concludes that the evidence establishes that the Veteran's restless legs syndrome is caused by his service-connected disabilities.

The Veteran asserts that his restless legs syndrome is secondary to his service-connected PTSD with panic disorder, including due to medication prescribed for his psychiatric symptoms; as well as his degenerative arthritis, lumbosacral spine (previously rated as low back strain) and associated right lower extremity radiculopathy with orchialgia. See, e.g., Board Hearing Transcript, March 2023; VA Form 21-4138, May 2023. 

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Relevant medical evidence of record includes a VA back examination, which noted a diagnosis of lumbar strain with a diagnosis date of 2005 as well as lumbosacral radiculopathy of the right lower extremity with a diagnosis date of 2013. See VA Back Conditions DBQ, August 2015. See also Manchester VA Treatment Records, January 2013 (noting exacerbation of back pain with
 degenerative arthritis, lumbosacral spine (previously rated as low back strain) and associated right lower extremity radiculopathy with orchialgia. See, e.g., Board Hearing Transcript, March 2023; VA Form 21-4138, May 2023. 

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Relevant medical evidence of record includes a VA back examination, which noted a diagnosis of lumbar strain with a diagnosis date of 2005 as well as lumbosacral radiculopathy of the right lower extremity with a diagnosis date of 2013. See VA Back Conditions DBQ, August 2015. See also Manchester VA Treatment Records, January 2013 (noting exacerbation of back pain with radiation to the bilateral lower extremities on occasion). 

The evidence also reflects that the Veteran was diagnosed with PTSD in 2015 and was prescribed Buspirone in July 2015. See Manchester VA Treatment Records, June 2015, July 2015. 

Later in July 2015, the Veteran's restless legs syndrome symptoms were noted in his treatment records, and he was prescribed Ropinirole for treatment. See, e.g., Manchester VA Treatment Records, July 2015. The prescribed Ropinirole was noted to improve his restless legs symptoms. See, e.g., Manchester VA Treatment Records, January 2016.

After July 2015, the Veteran was prescribed other medications for his psychiatric symptoms, to include paroxetine and then duloxetine. See Manchester VA Treatment Records, August 2015 (prescribing paroxetine), September 2016 (prescribing duloxetine). 

In February 2017, the Veteran reported that his restless legs syndrome symptoms had worsened. Shortly thereafter, he was prescribed an increased dose of Ropinirole for treatment. See Manchester VA Treatment Records, February 2017-March 2017. 

The relevant evidence of record also includes two VA Medical Opinion DBQs as well as two medical opinions submitted by the Veteran. A February 2021 VA examiner opined that the Veteran's claimed restless legs syndrome is less likely than not proximately due to or the result of his service-connected acquired psychiatric disorder. As a rationale, this examiner stated in part: "There is no objective evidence to support a current diagnosis for the claimed restless legs syndrome at this time." See Medical Opinion DBQ, February 2021. 

The Board finds that in suggesting a lack of objective evidence to support a current diagnosis, the February 2021 VA examiner failed to address the medical evidence of record reflecting that the Veteran's restless legs syndrome symptoms were treated and improved with prescribed medication. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (stating, "The Board must be able to conclude that a medical expert has applied valid medical analysis to the significant facts of the particular case in order to reach the conclusion submitted in the medical opinion"). As such, the Board finds this opinion to be inadequate and affords it no probative weight. 

In June 2021, the Veteran submitted a medical opinion of his VA provider, MD J.S., who opined that it is more likely than not that the Veteran's PTSD "is significantly contributing to his restless legs symptoms." As a rationale, the provider noted the severity of the Veteran's PTSD, "manifesting as daily nightmares, insomnia and periodic panic attacks even with multiple medications and regular PTSD-oriented therapy." The provider also noted the severity of the Veteran's restless legs syndrome symptoms, with only minimal relief from his prescribed Ropinirole. The provider concluded: "Given his severe, ongoing PTSD even with aggressive therapy and the continuing restless legs symptoms that cause significant, ongoing dysfunctional sleep, it is my professional opinion that it is more likely than not that the PTSD is significantly contributing to his restless legs symptoms." See Medical Opinion, MD J.S., June 2021. 

The Board finds that while the June 2021 medical opinion considered the Veteran's PTSD and restless legs syndrome manifestations, its conclusion is not otherwise supported by an explanation or medical analysis to allow the Board to make a fully informed decision. See Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007) (stating that a medical opinion must support its conclusion with an analysis that the Board can weigh, and a mere conclusion by a medical doctor is insufficient to allow the Board to make an informed decision). As such, the Board affords this opinion limited probative weight 

A July 2021 VA examiner offered an opinion as to conflicting medical evidence based upon a records review. This VA examiner opined that the Veteran's restless 

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legs syndrome (RLS) is less likely as not due to the Veteran's service-connected PTSD. As a rationale, this examiner stated in part: 

The two conditions are
 fully informed decision. See Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007) (stating that a medical opinion must support its conclusion with an analysis that the Board can weigh, and a mere conclusion by a medical doctor is insufficient to allow the Board to make an informed decision). As such, the Board affords this opinion limited probative weight 

A July 2021 VA examiner offered an opinion as to conflicting medical evidence based upon a records review. This VA examiner opined that the Veteran's restless 

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legs syndrome (RLS) is less likely as not due to the Veteran's service-connected PTSD. As a rationale, this examiner stated in part: 

The two conditions are separate and unrelated. . .  

"In most cases, the cause of RLS is unknown (called primary RLS). However, RLS has a genetic component and can be found in families where the onset of symptoms is before age 40. Specific gene variants have been associated with RLS. Evidence indicates that low levels of iron in the brain also may be responsible for RLS.

Considerable evidence also suggests that RLS is related to a dysfunction in one of the sections of the brain that control movement (called the basal ganglia) that use the brain chemical dopamine. Dopamine is needed to produce smooth, purposeful muscle activity and movement. Disruption of these pathways frequently results in involuntary movements. . . 

RLS also appears to be related to or accompany the following factors or underlying conditions: ...certain medications that may aggravate RLS symptoms, such as antinausea drugs (e.g. prochlorperazine or metoclopramide), antipsychotic drugs (e.g., haloperidol or phenothiazine derivatives), antidepressants that increase serotonin (e.g., fluoxetine or sertraline). . ."

[The June 2021] opinion noted PTSD was contributing to the RLS but did not note direct causation and did not cite evidence based articles to support a direct relationship. There is no medical literature demonstrating a causative relationship between RLS and PTSD. A plausible secondary relationship is not established. 

See Medical Opinion DBQ, July 2021.

The Board finds that the July 2021 VA examiner's rationale raised the question of whether the Veteran's prescribed psychiatric medications, reflected in the evidence of record, aggravated his restless legs syndrome. However, the July 2021 VA examiner did not adequately address this question. As such, the Board finds this opinion to be inadequate, and affords its conclusion no probative weight. 

The Veteran also submitted a private medical opinion of PA-C P.R.D., dated May 2023, which was based upon a records review. This private practitioner opined that "it is at least as likely as not that [the Veteran's] Restless Leg Syndrome is secondarily linked to his degenerative arthritis, lumbosacral spine; right lower extremity radiculopathy with orchialgia associated with degenerative arthritis, lumbosacral spine; and [PTSD] with panic disorder." As a rationale, this practitioner cited to medical literature "show[ing] a causal relationship between PTSD, medications used to treat PTSD, lumbar spine conditions, lumbar radiculopathy and RLS." Such literature included the following: 

"	A study titled, Restless Leg Syndrome and Sleep Quality in Lumbar Radiculopathy Patients, published in Behavioural Neurology in July 2014, stating in part: "The frequency of RLS was demonstrated to be 3%-10% in the general population.. . In the present study, RLS is accompanied in 68.1% of the patients with lumbar radiculopathy in the preoperative period and there was a significant improvement in the postoperative first month. The presence of radiculopathy can be considered as a very strong independent risk factor for RLS due to the fact that other risk factors such as uremia and diabetes likely to cause RLS were absent in our patients and a significant improvement was observed in the postoperative period." 

"	An article titled, Clinical features and diagnosis of restless legs syndrome and periodic limb movement disorder in adults, updated in June 2019, stating in part: "Several medications are known to exacerbate existing RLS or possibly precipitate RLS. Certain antidepressants, including mirtazapine and possibly tricyclic antidepressants, selective serotonergic reuptake inhibitors (SSRIs), and serotonin-norepinephrine reuptake inhibitors (SNRIs). . . Neuropathy related to a variety of underlying causes, including. . . radiculopathy have been observed with increased frequency in patients presenting with RLS compared with expected rates in the general population[.]" 

"	An article titled, Restless Legs Syndrome
 titled, Clinical features and diagnosis of restless legs syndrome and periodic limb movement disorder in adults, updated in June 2019, stating in part: "Several medications are known to exacerbate existing RLS or possibly precipitate RLS. Certain antidepressants, including mirtazapine and possibly tricyclic antidepressants, selective serotonergic reuptake inhibitors (SSRIs), and serotonin-norepinephrine reuptake inhibitors (SNRIs). . . Neuropathy related to a variety of underlying causes, including. . . radiculopathy have been observed with increased frequency in patients presenting with RLS compared with expected rates in the general population[.]" 

"	An article titled, Restless Legs Syndrome: Clinical Implications for Psychiatrists, published in Psychiatric Times in July 2017, stating in part: "While effective for treating symptoms of depression and anxiety, patients who take serotonergic antidepressants, such as SSRIs or SNRIs, are at increased risk for new-onset or worsening RLS. In one prospective study, 2% to 10% of patients treated with SSRIs (citalopram, escitalopram, sertraline, paroxetine, and fluoxetine) and SNRIs (duloxetine and venlafaxine) experienced treatment-emergent RLS. It has been proposed that the deleterious effects of SSRIs and SNRIs on RLS symptoms may result from serotonergically mediated dopamine inhibition."

The private practitioner noted that with respect to conditions noted as causing secondary RLS, the Veteran's "only known causes are his Lumbosacral radiculopathy and medications taken for his mental health conditions such as his prescribed Duloxetine." See Private Medical Opinion, PA-C P.R.D., May 2023. 

The Board finds that the May 2023 private medical opinion considered the Veteran's history of lumbosacral radiculopathy as well as PTSD, to include his treatment with psychiatric medications such as Duloxetine, including as reflected in his VA treatment records. The Board further finds that this private practitioner applied a valid medical analysis to the relevant facts of the case. The Board finds the May 2023 private medical opinion to be persuasive, particularly compared to the other medical opinions discussed above, and affords it great probative weight. See D'Aries v. Peake, 22 Vet. App. 97, 107 (2008) (stating, "The Board is permitted to favor one medical opinion over another provided it gives an adequate statement of its reasons and bases for doing so").

The Board concludes that the probative medical evidence of record persuasively establishes that the Veteran's restless legs syndrome is caused by his service-connected PTSD with panic disorder, degenerative arthritis, lumbosacral spine (previously rated as low back strain), and associated right lower extremity radiculopathy with orchialgia. Thus, the third element to establish secondary service connection is satisfied. 

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Accordingly, the claim for service connection for restless legs syndrome, as secondary to service-connected PTSD with panic disorder, degenerative arthritis, lumbosacral spine (previously rated as low back strain), and right lower extremity radiculopathy with orchialgia, is granted.  

 

P.M. DILORENZO

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Boldt, Allison W.

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.