Citation Nr: 1136070 Decision Date: 09/26/11 Archive Date: 10/03/11 DOCKET NO. 10-18 650 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for a heart disorder, including sinus bradycardia and coronary artery disease. 2. Entitlement to an initial compensable rating for right plantar fasciitis with heel spurs. 3. Entitlement to an initial compensable rating for left plantar fasciitis with heel spurs. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD John Francis, Counsel INTRODUCTION The Veteran served on active duty from May 1985 to October 2007. This appeal comes before the Board of Veterans' Appeals (Board) from a May 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina as part of the Benefits Delivery at Discharge (BDD) program. The purpose of the BDD program is to help ensure a smooth transition from military to civilian status by allowing service members to file pre-discharge claims for disability compensation with VA. In order to facilitate the quick processing of claims under the BDD program, the Virtual VA paperless claims processing system is utilized. Instead of paper, a highly secured electronic repository is used to store and review every document involved in the claims process. The use of this system allows VA to leverage information technology in order to more quickly and accurately decide a Veteran's claim for benefits. Because the current appeal was processed as part of the Virtual VA system, any future consideration of this appellant's case should take into consideration the existence of this electronic record. The Veteran testified before the Board sitting in Washington, D.C. in July 2011. A transcript of the hearing is associated with the claims file. The appeal is REMANDED to the RO via the Appeals Management Center (AMC) in Washington, D.C. REMAND The Veteran served as a U.S. Army officer retiring at the rank of Lieutenant Colonel and with several overseas duty assignments including in Southwest Asia. He contends that he experiences sinus bradycardia and coronary artery disease that first manifested in service and that his bilateral foot disorder is more severe than are contemplated by the initial ratings. Coronary Artery Disease Service treatment records are silent for any symptoms, diagnoses, or treatment for coronary artery disease. In 2004, the Veteran experienced an episode of syncope associated with choking on food. In January 2007, the Veteran underwent a physical examination that included an electrocardiogram (EKG). The study showed sinus bradycardia but was otherwise normal. Sinus bradycardia is a slow sinus rhythm with a heart rate less than 60 beats per minute in an adult. It is common in young adults and athletes, but it is also a manifestation of some disorders. Dorland's Illustrated Medical Dictionary, 223 (28th Ed., 1994). Outpatient military clinic records in February 2007 noted no coronary symptoms, diagnosed disorders, or referrals for further testing. However, in March 2007, the Veteran underwent an electron beam computed tomography (EBCT) scan of the heart. The report showed that the Veteran had a high coronary artery calcium score in the left anterior descending artery. The report explained that the score represented an increased risk for future coronary events over someone with no calcium but did not necessarily indicate the presence of a significantly narrowed artery. The result did not indicate that immediate medical care was necessary. Rather, the report encouraged the patient to proceed with all aspects of life without restriction including exercise. In September 2007, a VA contract physician noted the Veteran's report of the episode of syncope in 2004 but made no mention of the EKG and EBCT studies earlier in 2007. The physician noted the Veteran's report of using medication for hyperlipidemia and shortness of breath from asthma. The Veteran denied any history of angina, dizziness, cerebrovascular accident, congestive heart failure, or heart monitor testing. The Veteran reported that he had a negative echocardiogram stress test. A clinical examination of the heart and chest X-ray showed no deficits. The physician noted that an EKG showed normal sinus rhythm and a stress echocardiogram with good exercise tolerance (METS greater than 10) was without arrhythmias or other deficits. The physician concluded that there was no pathology or clinical indications of coronary artery disease and that the sinus bradycardia noted in January 2007 had resolved. At the July 2011 Board hearing, the Veteran submitted the results of another EBCT performed at a private facility in February 2010. The test results showed a lower calcium score in the left anterior descending artery but additional scores in other areas so that the total score was greater than that recorded in 2007. The written material associated with the test explained that a high score did not correspond directly with the percentage of narrowing of the arteries and that calcium deposits form years before any symptoms but do indicate a greater risk for future coronary artery disease. The Veteran also submitted a letter from a private cardiovascular physician who noted that the Veteran had asymptomatic coronary artery disease that was first diagnosed on the computed tomography scan in March 2007 and confirmed in further testing in February 2010. During the hearing, the Veteran stated that he was under treatment by cardiologists since retiring from service. He also stated that he presented the records of the 2007 testing to the VA contract physician in September 2007 but the physician declined to review them because he already had the service treatment file. The Board concludes that an additional examination and opinion is necessary to determine whether the Veteran has a current cardiovascular disability or only increased risk factors for future disease. The private cardiologist diagnosed "asymptomatic coronary artery disease" based on test results in 2007. However, the test material explained that the results showed an increased risk for future disease but not that there was reduced arterial flow or that any restriction of activities was warranted. The VA contract physician found no indications of coronary artery disease. He noted that bradycardia had resolved and that a normal exercise stress test demonstrating no functional deficiencies. However, this physician did not comment on the EBCT testing or explain why the test results did or did not support a diagnosis of a heart disability. Further, the Veteran indicated that he has been receiving treatment from a private cardiologist. As these records are pertinent to a diagnosis of a current disability, a request for these records is necessary prior to deciding the claim. 38 C.F.R. § 3.3159 (c) (2010). Bilateral Foot Disorders Service treatment records showed that the Veteran was diagnosed with bilateral plantar fasciitis and heel pain as early as one year prior to treatment by a podiatrist in November 1998. The podiatrist prescribed custom orthotics. Outpatient treatment records showed that the Veteran continued to experience foot pain exacerbated by strenuous exercise or activity and was issued new orthotics in 2006. In March 2007, a military podiatrist diagnosed bilateral plantar fasciitis, pes cavus, and hallux valgus. X-rays showed bilateral degenerative changes and joint narrowing at the first metatarsal joint. In June 2007, X-rays showed a moderate sized right heel spur. In September 2007 a VA contract physician noted the Veteran's report of intermittent pain in both feet since 1997. The episodes of pain occurred three times per day lasting several hours and required the use of pain medication to function. He experienced difficulty climbing stairs in the morning and standing and walking for extended periods of time. On examination, the physician noted that there was no pain on motion, edema, disrobed circulation, weakness, or atrophy. There was no tenderness on palpation of the plantar surfaces to metatarsal joints or pain on dorsiflextion of the toes. The physician noted slight hallux valgus be nor deformities, pes planus, pes cavus, or hammertoes. X-rays showed osteoarthritis of the first metatarsal joint and heel spurs. In May 2008, the RO granted separate service connection and noncompensable ratings for right and left plantar fasciitis with heel spurs under Diagnostic Code 5020 for synovitis and hallux valgus with osteoarthritis of the great toes under Diagnostic Code 5280 for hallux valgus. In a July 2011 Board hearing, the Veteran stated that he was not asked to remove his shoes and that he did not undergo X-rays of his feet at the time of the VA contract examination in September 2011. The Veteran submitted an April 2011 letter from a private podiatrist who noted that the Veteran continued to experience heel pain and limitation of motion of the great toe joint that exacerbated the heel pain and caused limping. The Veteran stated that he stopped running for exercise and that he receives on-going foot care including steroid injections provided by the military medical insurance system but did not identify the provider. The Board concludes that an additional VA examination is necessary to decide the claim. Notwithstanding the inconsistency in the reporting of the conduct of the VA contract examination, the observations and diagnoses made by the VA contract physician in September 2007 are substantially different from that shown in the history of foot treatment during the last ten years of service and from the observations of the military podiatrist in March 2007. Further, the Veteran reported that he has received treatment for foot pain since service and records of this treatment are pertinent to the claim for increased ratings. Accordingly, the case is REMANDED for the following action: 1. Request from the Veteran the identity and address of the private physicians or military clinicians who provided treatment for cardiovascular disease and bilateral foot disorders since October 2007. Request that the Veteran provide authorization, and if granted, request records of treatment from these medical providers. Associate any records received with the claims file. 2. Then, schedule the Veteran for a VA examination by a cardiologist. Request that the physician review the claims file including the results of electron beam computed tomography scans in March 2007 and February 2010. Request that the physician examine the Veteran and order any medically indicated functional testing. a. Request that the physician provide an opinion as to whether the Veteran currently has coronary artery disease or any other form of cardiovascular disease that is at least as likely as not (50 percent possibility or greater) first manifested in service or is related to any aspect of service. b. Request that the physician comment on any diagnoses or opinions of record by the VA contract, private, or military clinic providers and specifically discuss whether the high arterial calcium measurements in 2007 and 2010 or the 2007 EKG report of sinus bradycardia represent the onset of disease or only increased risk for the disease and whether any calcium plaque accumulation caused reduced cardiovascular function in the Veteran. 3. Schedule the Veteran for a VA foot examination with a podiatrist. Request that the podiatrist review the claims file and note the review in the examination report. Request that the podiatrist evaluate the Veteran's foot disability including plantar fasciitis, heel spurs, great toe arthritis, hallux valgus, pes planus, pes cavus, or any other deformities and the impact of the disability on the Veteran's ability to perform specific forms of gainful employment. 4. Review the claims file to ensure that all the foregoing requested development is completed, and arrange for any additional development indicated. Then, readjudicate the claim for service connection for a heart disorder and for initial compensable ratings for right and left plantar fasciitis with heel spurs. If any benefit sought remains denied, issue an appropriate supplemental statement of the case and provide the appellant and his representative the requisite time period to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. The purpose of this remand is to assist the appellant with the development of his claim. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). No action is required of the appellant until further notice. However, the Board takes this opportunity to advise the appellant that the conduct of the efforts as directed in this remand, as well as any other development deemed necessary, is needed for a comprehensive and correct adjudication of his claims. His cooperation in VA's efforts to develop his claims, including reporting for any scheduled VA examination, is both critical and appreciated. The appellant is also advised that failure to report for any scheduled examination may result in the denial of a claim. 38 C.F.R. § 3.655 (2010). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West 2002 & Supp. 2010). _________________________________________________ DENNIS F. CHIAPPETTA Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2010).