Citation Nr: 0810425	
Decision Date: 03/28/08    Archive Date: 04/09/08

DOCKET NO.  01-01 333	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Cleveland, 
Ohio


THE ISSUE

Entitlement to service connection for ankle disability 
secondary to service-connected disabilities of the spine.


REPRESENTATION

Appellant represented by:	The American Legion


ATTORNEY FOR THE BOARD

A. Muhlfeld, Associate Counsel




INTRODUCTION

The veteran had active military service from January 1960 to 
December 1962. 

This matter comes before the Board of Veterans' Appeals 
(Board) on appeal of a January 2000 rating decision by the 
Department of Veterans Affairs (VA) Regional Office (RO) in 
Cleveland, Ohio.


FINDING OF FACT

It is as likely as not that the veteran's bilateral ankle 
arthritis was caused by his service-connected disabilities of 
the spine.


CONCLUSION OF LAW

Service connection for bilateral ankle arthritis secondary to 
service-connected disability is warranted.  38 U.S.C.A. 
§ 1131 (West 2002); 38 C.F.R. § 3.310 (2007).


REASONS AND BASES FOR FINDING AND CONCLUSION

In this case, the veteran contends that his bilateral ankle 
disability is secondary to his service-connected spinal 
disabilities, including ankylosis spondylitis.

In this regard, the Board notes that a disability that is 
proximately due to or the result of a service-connected 
disease or injury is considered service-connected, and when 
thus established, this secondary condition is considered a 
part of the original condition.  38 C.F.R. § 3.310(a) (2007).

The veteran was afforded a VA examination in January 2003.  
At this examination, x-ray findings of the ankles revealed 
evidence of prior surgery related to the soft tissues, and 
the examiner noted that he suspected a vascular procedure of 
the distal left foreleg medially.  The radiologist also noted 
osseous structures, joint spaces and soft tissues notable for 
extensive arterial calcification, and the impression was that 
the study was notable for findings consistent with 
vascularization.  At the January 2003 examination, the 
examiner noted that the veteran was initially diagnosed with 
ankylosing spondylitis and went on to develop typical 
physical manifestations, and noted that the veteran was 
currently complaining of increasing physical discomfort in 
both lower extremities.  The veteran reported that he was 
diagnosed with osteoarthritis in 1981, and stated that since 
that time, it had become significantly worse.  The veteran 
stated that he could not walk farther than 10-20 yards 
without resting, and noted that his pain was primarily 
localized in the hips and knees, but he stated that his 
ankles swelled and became very painful if he is on them for 
any length of time.

On examination, the VA examiner noted that the veteran was 
hunched over, and stated that he had mild valgus deformities 
of both ankles, worse on the left than the right with 10 
degrees of valgus in the left and 7 degrees on the right.  
The examiner noted that on the right, the veteran swings into 
neutral at toe raise, and on the left, he swings into 5 
degrees of continued valgus.  The examiner also noted mild 
tenderness along the posterior tibial tendon on the left, as 
well as the right, and noted a normal subtalar rock 
bilaterally.  The examiner noted full range of motion at both 
ankles, no effusion, and negative anterior drawer 
bilaterally.  Further, the veteran had mild pes planus 
deformities.  The examiner gave an impression of inflammatory 
arthritis affecting the lower extremities with diffuse joint 
complaints.

Regarding etiology of the ankle disability, the examiner 
noted that the veteran had been diagnosed in the past with 
ankylosing spondylitis, as well as a nonspecific inflammatory 
arthritis in conjunction with his mild, but increasing 
osteoarthritis.  The examiner noted that the veteran's 
current level of disability was moderate to severe, and 
opined that the majority of his disability was attributable 
to his spine disorder.  The examiner also noted that his 
lower extremity discomfort was consistent with his diagnosis 
of inflammatory arthritis, which the examiner noted limited 
his daily activity.  The examiner stated that his lower 
extremity discomfort was likely related in some way to the 
actual change in his gait pattern, as well as his positional 
pattern secondary to his spine.  However, his discomfort in 
his lower extremities, hips, knees and ankles are as equally 
likely secondary to his underlying inflammatory arthritis, 
but the examiner stated that in either case, it seemed more 
likely than not that his current level of disability was 
secondary to his service-connected diagnosis of ankylosing 
spondylitis and the clinical manifestation.  The examiner 
opined that the veteran will continue to have the disability, 
which will likely escalate in the future.

In addition to this examination, the record contains an 
August 1999 letter from B.B., M.D., stating that the veteran 
had been recently diagnosed with ankylosing spondylitis, and 
opined that it was likely that the ankylosing spondylitis was 
the cause of his hip and leg problems and possibly knee and 
ankle problems.

The record also contains a July 2004 VA examination, where 
the examiner, Y.K., M.D. noted that the veteran had flat feet 
and stated that his heels rolled outwards and longitudinal 
arches had completely flattened out.  The examiner diagnosed 
the veteran with flat feet with mild bunion formation of the 
right MP joint of the big toe.  An x-ray report shows that 
the veteran had changes of the ankle joints consistent with 
arthritis.  In a September 2004 addendum to the July 2004 
examination, Dr. K. commented that the veteran's left ankle 
arthritic changes were related to his flat feet and rolling 
outward of his heels, causing poor weight bearing on his 
ankle joints and opined that his arthritic ankle changes were 
not related to spinal or SI joint condition, but opined that 
the veteran was born with flat feet and that military service 
did not give him flat feet.  In another addendum dated in 
November 2004, the examiner stated that the veteran's ankle 
and foot problems were not related to ankylosing spondylitis, 
but were considered due to flat feet problems.  The examiner 
also noted that the veteran's ankylosis spondylitis created 
altered gait patterns in the spine and sacroiliac joint due 
to complete fusion of the spine and SI joint.

In this case, after considering all the evidence of record, 
and providing the veteran with the benefit of the doubt, the 
Board concludes that he is entitled to service connection for 
his bilateral ankle disability, secondary to his spinal 
disabilities.  Here, the Board points out that even though 
the evidence of record reflects discrepancies of opinion 
regarding the cause of the veteran's bilateral ankle 
disability, specifically whether it was caused or aggravated 
by his spinal disabilities, under the benefit-of-the-doubt 
rule embodied in 38 U.S.C.A. § 5107(b)(West 2002), in order 
for a claimant to prevail, there need not be a preponderance 
of the evidence in the veteran's favor, but only an 
approximate balance of the positive and negative evidence.  
See Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990).  Here, 
the January 2003 examiner diagnosed the veteran with 
inflammatory arthritis affecting the lower extremities with 
diffuse joint complaints, and specifically opined that 
"lower extremity discomfort" (which the Board finds 
includes the bilateral ankle disability, as it was mentioned 
earlier in the examination) was likely related in some way to 
the change in gait pattern and positional pattern secondary 
to the spine, and also stated that the majority of his 
disability was attributable to his spine disorder.  Here, 
although the examiner could have been clearer in his 
assessment, this opinion demonstrates a connection between 
the veteran's currently diagnosed bilateral ankle disability 
and his spinal disabilities, including ankylosing 
spondylitis.  Further, Dr. K. stated in his November 2004 
addendum to his July 2004 opinion, that the veteran's 
ankylosis spondylitis created altered gait patterns in the 
spine and sacroiliac joint due to complete fusion of the 
spine and SI joint.  Considering this statement together with 
the January 2003 examiner's statement that lower extremity 
discomfort was likely related in some way to a change in gait 
pattern, the Board finds that the medical evidence of record 
establishes a connection between the veteran's bilateral 
ankle disability and his altered gait, which, as noted by Dr. 
K., is a direct result of his ankylosing spondylitis.  

Although the January 2003 examiner also commented that the 
discomfort in his lower extremities, hips, knees and ankles 
are as equally likely secondary to his underlying 
inflammatory arthritis; he continued on to state that in 
either case, it seemed more likely than not that his current 
level of disability was secondary to his service-connected 
diagnosis of ankylosing spondylitis and the clinical 
manifestation.  In any event, even if this subsequent 
statement results in a balance between negative and positive 
evidence regarding the etiology of the bilateral ankle 
disability, when considering all the evidence of record, the 
evidence is still in relative equipoise and therefore, the 
veteran is entitled to the benefit of the doubt.

The Board notes that the record includes a July 2004 VA 
examination by Dr. K., including September and November 2004 
addendums, which opined that the veteran's left ankle 
arthritic changes were related to his flat feet and rolling 
outward of his heels, causing poor weight bearing on his 
ankle joints and opined that his arthritic ankle changes were 
not related to spinal or SI joint condition, but that the 
veteran was born with flat feet and that military service did 
not give him flat feet.  Dr. K. also stated that the 
veteran's ankle and foot problems were not related to 
ankylosing spondylitis, but were considered due to flat feet 
problems.  However, Dr. K. gave no rationale or indication as 
to how he determined that the veteran had pes planus (flat 
feet) since he was born, and after examining the record, the 
Board notes that Dr. K.'s opinion is not supported by the 
record, as there is no evidence which indicates that the 
veteran had pes planus since birth.  On the contrary, the 
service entrance and discharge examinations make no mention 
of pes planus, and the first diagnosis of pes planus in the 
record is found in a January 1967 VA examination where the 
examiner diagnosed the veteran with nonsymptomatic third 
degree bilateral pes planus.  As such, because the 2004 
examiner did not provide a rationale regarding the conclusion 
that the veteran has suffered with pes planus since birth, 
and in addition, did not even mention, much less explain, the 
January 1967 diagnosis of pes planus, (which makes the Board 
question whether the examiner even saw this 1967 diagnosis); 
nor did the examiner explain the absence of pes planus noted 
at entrance into the military (thereby contradicting his 
conclusion that the veteran had flat feet since birth); the 
Board finds this medical opinion to be of less probative 
value than the January 2003 opinion which did not contain 
inaccuracies or inconsistencies, and was supported by a 
review of the record.

In deciding this issue the Board has considered the 
provisions of 38 U.S.C.A. § 5107 (benefit-of-the-doubt).  
Under the of benefit-of-the-doubt standard, when a veteran 
seeks benefits and the evidence is in relative equipoise 
regarding any issue material to the determination of a 
matter, the law dictates that the benefit of the doubt 
belongs to the veteran.  38 U.S.C.A. § 5107; 38 C.F.R. § 
3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990).  The 
Board has considered the benefit-of-the-doubt doctrine, and 
finds that the record provides at least an approximate 
balance of negative and positive evidence on the merits.  
Therefore, on the basis of the above analysis, and after 
consideration of all of the evidence, the Board finds it is 
at least as likely as not that the veteran's bilateral ankle 
arthritis is due to his service-connected spinal 
disabilities.  38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; 
Gilbert, supra, at 57-58.


ORDER

Entitlement to service connection for arthritis of the ankles 
secondary to service-connected spinal disabilities is 
granted.



________________________________
MARK F. HALSEY
Veterans Law Judge, Board of Veterans' Appeals


 Department of Veterans Affairs