Citation NR: 9736656 Decision Date: 10/31/97 Archive Date: 11/05/97 DOCKET NO. 94-25 210 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUE Entitlement to service connection for Dupuytren's contractures of the hands and feet, hypertension and skin disabilities. REPRESENTATION Vietnam Veterans of America WITNESS AT HEARING ON APPEAL The appellant ATTORNEY FOR THE BOARD R. A. Caffery, Counsel INTRODUCTION The veteran served on active duty from November 1970 to May 1972. In a February 1985 rating action the Department of Veterans Affairs (VA) denied entitlement to service connection for Dupuytren's contractures of the hands and feet, dermatomycosis and hyperhidrosis. In March 1990 the veteran submitted additional information to reopen his claim. In a March 1994 rating action service connection was again denied for Dupuytren's contractures of the hands and feet. The veteran disagreed with that decision. In rating actions in April 1994 and January 1995 service connection was denied for hypertension and additional skin conditions including porphyria cutanea tarda, dermatomycosis, hyperhidrosis, acne rosacea, telangiectasia, dyshidrotic eczema, scleroderma, bullous lesions, milia, erythema and folliculitis. The veteran appealed from the denials of service connection for those conditions. The issues developed for appellate review included service connection for a liver disability, a bladder disability, Raynaud's disease, dermatomyositis and a condition involving the penis. However, by written communication of July 1997, the veteran specifically withdrew his appeal regarding those issues. Thus, those matters are no longer in appellate status, and will not be further considered in this decision. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends, in substance, that service connection should be established for Dupuytren's contractures of the hands and feet, hypertension and the skin disorders at issue since those conditions either developed during his military service or resulted from exposure to Agent Orange during service. It is maintained that a service department physician's reference to a fractured hand in 1968 actually represented the beginning of the Dupuytren's contractures since a subsequent X-ray after service showed that he had not had a fracture of the hand. It is further contended that the veteran's skin disorders may be related to his service- connected pilonidal cyst residuals and it is requested that, if an allowance of service connection for the skin conditions is not possible on the present record, that an independent medical expert opinion be obtained regarding whether there is any relationship between the pilonidal cyst residuals and the skin conditions. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims files. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence is against the veteran's claims for service connection for Dupuytren's contractures of the hands and feet, hypertension and the claimed skin conditions. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained by the regional office. 2. Dupuytren's contractures of the hands and feet were not demonstrated during the veteran's active military service. That condition was initially medically demonstrated many years after the veteran's separation from service. It is not of service origin and no medical authority has related it to herbicide exposure. 3. Chronic skin conditions were not demonstrated during the veteran's active military service. 4. Skin conditions including acne rosacea, dermatomycosis and hyperhidrosis were initially medically demonstrated many years after the veteran's release from active duty. No diagnosed skin condition has been related to his pilonidal cyst or any herbicide exposure by any medical authority. 5. Porphyria cutanea tarda has not been medically demonstrated. 6. Hypertension was not shown during the veteran’s active service or for many years thereafter and no medical authority has related it to herbicide exposure. 7. The veteran's appeal regarding the issue of service connection for skin diseases does not involve a question of medical complexity or controversy. CONCLUSIONS OF LAW 1. Dupuytren's contractures of the hands and feet, hypertension and skin disorders were not incurred in or aggravated during the veteran's active military service or as the result of any incident or exposure during service. Acne rosacea and hypertension may not be presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (1997). 2. An independent medical expert's opinion is not warranted. 38 U.S.C.A. § 7109 (West 1991); 38 C.F.R. § 20.901 (1997). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board notes that it has found the veteran's claims are "well grounded" within the meaning of 38 U.S.C.A. § 5107(a); effective on and after September 1, 1989. That is, the Board finds that he has submitted claims which are plausible. The Board is also satisfied that all relevant facts have been properly developed. I. The Claim for Service Connection for Dupuytren's Contractures of the Hands and Feet. The veteran's service medical records, including the report of his physical examination for separation from service, do not reflect any reference to Dupuytren's contractures of the hands and feet. He was hospitalized during service, in January 1972, for recurrent problems with pilonidal disease for approximately two years. It was noted that he had previously had surgery in Vietnam in September 1971 and it was also reported that he had had a fractured hand in 1968. The veteran's initial claim for VA disability benefits was submitted August 1973. The only disability claimed was a pilonidal cyst, which he described as aggravated by service in October 1970. The veteran was examined by the VA in September 1973. There was a tender area over the previously operated pilonidal cyst. The diagnosis was recurrent active inflamed pilonidal cyst. There was no reference to Dupuytren's contractures of the hands and feet. In an October 1973 rating action service connection was granted for residuals of pilonidal cyst, rated noncompensable. In an April 1982 claim, the veteran referred to various conditions including nodules on his hands and feet in May 1971. A VA X-ray study of the veteran's left hand in June 1982 showed a contraction deformity of the ring finger. No old fracture was evident. The veteran was afforded a VA Agent Orange examination in June 1982. The findings included Dupuytren's contractures of the hands, Dupuytren’s palmar fibrosis and cutaneous nodules of both insteps. The veteran was hospitalized by the VA during March 1983 and the diagnosis was Dupuytren's contractures of the hands and feet. December 1984 statements by the veteran's parents and an acquaintance were to the effect that over the past several years his hands and feet had developed hard nodules. The veteran was examined by the VA in August 1991 and the diagnoses included bilateral Dupuytren's contractures of the hands and bilateral plantar fasciae nodules. When the veteran was examined by the VA in October 1992 the diagnoses included Dupuytren's contractures of each hand and fibromatosis of the soles of the feet compatible with Dupuytren's contractures. In a July 1997 statement, Edward C. McElfresh, M.D., reflected that the veteran had a rather severe case of Dupuytren's contracture. He related that the veteran had shown him a report from Vietnam showing that he had what appeared to be a contracture of the left ring finger which was probably the beginning of the Dupuytren's contracture. The veteran raised the question of whether Agent Orange could cause the Dupuytren's contracture. He also had other questions. Dr. McElfresh stated he was unable to answer the veteran's questions and had referred him to other experts in the field. In this case, as indicated previously, the veteran's service medical records do not reflect any reference to Dupuytren's contractures of the hands and feet. The report mentioned by Dr. McElfresh is not of record and the veteran has apparently elected to not place it of record, although he has submitted extensive peripheral material, including numerous extracts from medical texts and abstracts. While it is possible that he is referring to the January 1972 hospital report, that clearly refers only to a hand problem in 1968, clearly before service. That condition was initially medically demonstrated many years following his separation from military service. The reference to a fracture of the veteran's left hand in 1968 was apparently based on medical history furnished by the veteran as there were no findings regarding any such fracture or other disorder of the hands or fingers during service or on subsequent VA examinations. The veteran's service records reflect that he served in Vietnam during service; thus, he is presumed to have been exposed to Agent Orange during service. 38 C.F.R. § 3.307(a)(6). However, Dupuytren's contractures are not among those diseases included in 38 C.F.R. § 3.309(e) for which service connection may be presumed based on exposure to Agent Orange during service and there is no medical opinion of record which would support such a thesis. Accordingly, under the circumstances of this case, it follows that service connection for Dupuytren's contractures of the hands and feet would not be warranted. II. The Claim for Service Connection for Skin Disabilities. The veteran's service medical records, including the report of his physical examination for separation from service do not reflect any reference to any of the claimed skin disorders. When the veteran was examined by the VA in September 1973 the skin was reported to be negative apart from the findings regarding the pilonidal cyst residuals. On a VA dermatological examination in June 1982 diagnoses were made of dermatomycosis and hyperhidrosis. However, that was many years following the veteran's separation from military service. Other skin disorders were later diagnosed including a history of facial telangiectasis when the veteran was hospitalized by the VA during April 1989; dyshidrosis of the feet on a VA outpatient treatment record in November 1990; and mild acne rosacea of the face on a VA dermatological examination in October 1992. As in the case of the other skin disorders, those conditions were initially manifested many years following the veteran's separation from service. Under the regulations providing for service connection on a presumptive basis for conditions based on exposure to Agent Orange during service, chloracne is listed; however, that condition must become manifest to a degree of 10 percent or more within a year after the last date on which the veteran was exposed to Agent Orange during service. 38 C.F.R. §§ 3.307, 3.309. Porphyria cutanea tarda is also listed for presumptive service connection under those regulations; however, that condition has not been medically demonstrated in this case. The remaining skin disorders for which the veteran seeks service connection are not included among the conditions listed for presumptive service connection based on exposure to Agent Orange in service. Although it has been contended that there is a relationship between the veteran's pilonidal cyst residuals and the claimed skin disorders; there has been no medical evidence or authority submitted to substantiate that claim and in that aspect, his claim is not well grounded. Accordingly, an evidentiary basis which would warrant entitlement to service connection for the claimed skin disorders has not been established. The Board has considered the request for an opinion by an independent medical expert; however, in view of the above discussion, the Board does not believe that such an opinion is necessary for an equitable disposition of the matter of service connection for skin diseases as a question of medical controversy or complexity is not presented. 38 U.S.C.A. § 7109; 38 C.F.R. § 20.901. The veteran has submitted numerous extracts from medical texts and abstracts and indicated that he has researched the area extensively for many years. On review of the material he submitted, the Board cannot discern that it provides significant support for his position or even that it establishes that a valid question of medical controversy or complexity exists. III The Claim for Service Connection for Hypertension The veteran’s service medical records do not reflect the presence of hypertension or any elevated blood pressure readings. When he was examined by the VA in September 1973, his blood pressure was 118/74 (normal). At his Agent Orange examination in June 1982 a blood pressure of 108/88 was recorded. Hypertension was initially shown many years after the veteran’s separation from service. That condition is not one of those listed for consideration based upon exposure to Agent Orange and no medical authority has drawn any connection between his hypertension and service. Service connection may be granted for hypertension if it is found to a disabling degree within a year of separation; however that is clearly not the case here. Accordingly, service connection for hypertension is not warranted. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (1997). The Board has carefully reviewed the entire record in this case, including the testimony presented by the veteran at the August 1994 hearing at the regional office; however, the Board does not find the evidence to be so evenly balanced that there is doubt as to any material issue regarding any of the matters on appeal. 38 U.S.C.A. § 5107. ORDER Entitlement to service connection for Dupuytren's contractures of the hands and feet, hypertension and skin disabilities is not established. The appeal is denied. ROBERT D. PHILIPP Member, Board of Veterans' Appeals NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991 & Supp. 1997), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402, 102 Stat. 4105, 4122 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals. - 2 -