Citation Nr: 1318776 Decision Date: 06/10/13 Archive Date: 06/21/13 DOCKET NO. 12-27 135A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES Entitlement to service connection for Raynaud's phenomenon, bilateral feet (claimed as cold injury to bilateral feet). (The issues of entitlement to increased ratings for cold injury residuals of the right and left hands with Raynaud's are addressed in a separate decision.) ATTORNEY FOR THE BOARD A. Spector, Associate Counsel INTRODUCTION The Veteran had active service from February 1982 to January 1987. This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from a June 2011 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, which denied the claim of service connection for Raynaud's phenomenon of the bilateral feet. The Veteran filed a notice of disagreement (NOD) with this determination in July 2011, and timely perfected her appeal in October 2012. FINDING OF FACT The Veteran's currently diagnosed Raynaud's phenomenon of the bilateral feet did not have its onset in service and is not otherwise related to service. CONCLUSION OF LAW The criteria for a grant of service connection for Raynaud's phenomenon of the bilateral feet have not been met. 38 U.S.C.A. §§ 1101, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide in accordance with 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Here, the duty to notify was satisfied by way of a letter sent to the Veteran in July 2010 that fully addressed all notice elements and was sent prior to the initial AOJ decision in this matter. The letter informed the Veteran of what evidence was required to substantiate the claim and of the Veteran's and VA's respective duties for obtaining evidence. The letter also provided notice regarding how disability ratings and effective dates are assigned if service connection is awarded. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service treatment records and other pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The VA has also done everything reasonably possible to assist the Veteran with respect to her claim for benefits, such as obtaining private and VA medical records, and providing the Veteran with VA examinations in June 1999, February 2000, October 2003, August 2010, and April 2011. Additionally, the Veteran has not indicated that she has received additional treatment for Raynaud's phenomenon of the bilateral feet. The Board thus concludes that there are no additional records outstanding with respect to that claim. Consequently, the duty to notify and assist has been satisfied as to the claim now being finally decided on appeal. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). II. Service Connection Service connection will be granted if it is shown that the Veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C.A. §§ 1131; 38 C.F.R. § 3.303. Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). To establish service connection, there must be competent evidence of: (1) a current disability; (2) an in-service occurrence or aggravation of a disease or injury; and (3) a nexus between an in-service injury or disease and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). 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. Certain listed disabilities, to include Raynaud's disease, may be presumed to have been incurred during active military service if manifested to a degree of 10 percent within the first year following 90 days or more active service. 38 U.S.C.A. §§ 1101, 1112, 1137 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.307, 3.309 (2012). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for the evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded to the Veteran. The Veteran contends that Raynaud's syndrome of her bilateral feet had its onset while on active duty. Specifically, the Veteran reported that Raynaud's phenomenon of her bilateral feet is a result of cold weather injury while stationed in Germany. The Veteran's service treatment records show complaints of painful hands, numbness, and tingling in her fingers, diagnosed as a cold weather injury in February 1985, January 1986, April 1986, May 1986, and August 1986. A January 1986 record shows that the Veteran complained of right foot pain at her instep when walking or running. A diagnosis of pes planus was noted. A February 1986 record noted painful arches for the past seven months. The Veteran tried arch supports in boots, without good results. A diagnosis of mild pes planus was noted. Due to complaints of plantar pain, a March 1986 x-ray was performed, which showed that both feet appeared to be normal. Additionally, an August 1986 treatment record reveals subjective complaints of numbness in her fingertips, and the examiner noted normal feet. On the May 1986 Report of Medical History, the Veteran noted foot trouble and cold weather injury to hands. At that time, the examiner noted right plantar arch pain. The September 1986 Medical Board examination and report again noted painful hands in cold weather and a diagnosis of cold weather injury to hands, and was silent as to a cold weather injury to the feet. Service treatment records and examinations are silent for any treatment or diagnoses of Raynaud's phenomenon or cold injury to the feet. The Veteran has reported that in February 1985, while she was stationed in Germany while participating in the brigade run in extremely cold weather, she suffered frostbite to her hands and feet. She further stated that she stood on the parade field in the cold following orders. The Veteran also reported that she complained about her feet in service. Additionally, she noted such symptoms as numbness and no circulation in her feet, and having to use a heater to warm her feet at work. At a June 1999 VA examination, the Veteran reported at the time of frostbite, she felt numbness and tingling in both hands, as well as diminished sensation in the fingers. She noted that she was diagnosed with Raynaud's disease in her hands. She also reported that she had the same problem in both feet, especially in the toes. Upon examination, the examiner noted that the Veteran's feet revealed pulses to be present. Additionally, there was no nail dystrophy, fungal infection, and skin was normal. She reported pain over the dorsum of the feet, mostly when walking or when the weather changes. Private treatment records show a diagnosis of Raynaud's dating back to August 1998. In an initial December 2001 psychological intake summer, the Veteran reported that she had elevated anxiety and depressed mood due to longstanding medical problems involving her hands. She reported that her hands were frostbitten during her tour in the Air Force. The Veteran was afforded a cold injury VA examination in February 2000. The Veteran reported that she suffered frostbite to her hands and feet. She described excruciating pain and numbness involving her toes. She reported she was diagnosed with Raynaud's in 1999 when she was seen by a private rheumatologist. Studies performed showed that the Veteran's feet did not show any vasospastic phenomenon. The examiner concluded that claims of foot involvement could not be documented because there was no vasospastic phenomenon indentified following provocative test. The Veteran was afforded a cold injury VA examination in October 2003. The Veteran's complaints consisted mainly of cold injury residuals of the hands. No complaints were made at that time in reference to any foot disability. Upon examination, the examiner noted that the Veteran's feet were essentially negative. The examiner listed a diagnosis of Raynaud's syndrome, with no specificity to hands or feet, and a history of cold injury to the hands and feet. Additionally, at the October 2003 VA joints examination, the examiner concluded that the Veteran's Raynaud's was associated with the cold injury to her bilateral hands while on active duty service. An etiology of the Veteran's feet disability was not rendered at that time. At the August 2010 cold injury VA examination, the Veteran reported that while stationed in Germany, her feet were affected by the cold weather, but not severely. She reported that she had frostbite on her toes. She complained of pain in the tips of her toes, which was worse at night, during cold weather, and walking or standing. She also reported tingling, numbness, stiffness of joints, weakness, and muscle cramps. She also stated that her feet were pale and blotchy. Upon examination, sensory, reflex, and motor examinations were listed as normal. Skin examination showed cooler than normal skin temperature, however, color, thickness, moisture, texture, and hair growth were all listed as normal. There was no evidence of fungus, nails affected, callus formation, or scars. Cold injury residuals with Raynaud's were listed as a diagnoses, with no specificity to hands or feet. An etiology of the Veteran's feet disability was not rendered at that time. The Veteran submitted February 2011 lay statements detailing her feet symptomatology. One witness observed the Veteran having traumatic episodes of numbness, pain, and cramping in her feet and toes. Additionally, a co-worker stated that the Veteran would arrive at work in tears because her feet were extremely cold and numb. The Veteran's sister-in-law reported that the Veteran experienced extreme exposure to cold climate and suffered frostbite to her feet. She also witnessed the Veteran stepping in place to increase circulation in her feet. The Veteran was afforded another VA examination in April 2011. The Veteran reported that she had frostbite to her bilateral feet while in Germany during a Brigade run for two hours in the very cold temperatures. She could not feel her feet and hands, and was sent to the clinic. Since then, she had pain in the feet arch and tingling. She was given inserts, which helped. Her feet were cold and she had to wear socks at night, which was worse during the winter. She also reported piercing pain on the arches when she walked or bore weight. She reported pain, numbness, tingling, and stiffness of the joints of part or all of her toes and feet. Upon examination, the Veteran was noted to have no history of tissue loss. The Veteran reported that she experienced Raynaud's syndrome attacks that involved color changes (white, blue, and red) in her fingers and numbness that lasted for 30 to 60 minutes one or more times daily. The Veteran reported tingling and cold sensitivity, but she denied weakness, swelling, muscle cramps, recurrent fungal infections, abnormal color, ulcerations, nail abnormalities, and arthritis. The examiner noted that the left and right feet were cooler than normal, but skin thickness, moisture, texture, and hair growth were normal. Additionally, the nails were not affected, and there were no callus formations, infections, ulcerations, or scars. The VA examiner diagnosed the Veteran with Raynaud's phenomenon of the bilateral feet, residual cold injury of the lower extremities. The examiner stated that numbness and pain in feet claimed as residuals of cold injury of the lower extremities was less likely than not (less than 50/50 probability) caused by or a result of cold exposure during active service. The examiner noted that the Veteran's service treatment records did not show complaints of pain, numbness, tingling, or coldness in her feet. He noted she complained of right foot arch pain, which was attributed to her flat feet. The examiner stated the Veteran complained of pain in her feet on weight bearing and tenderness on manipulation in addition to pain, numbness, and tingling during cold temperatures at the present time and that her private physician diagnosed her with Raynaud's phenomenon. The examiner noted that the Veteran had signs of Raynaud's in her hands while in active service, but not in her feet; that she had complained only of pain in the arch of one foot. There was no record of pain, numbness, and tingling of her feet in the service treatment records; she did not complain of problems with her feet until 1998 per review of the claims file. The examiner noted that pathogenesis of Raynaud's phenomenon is abnormal vasoconstriction of digital arteries and cutaneous arterioles due to a local defect in normal vascular response. He added that the literature states most investigators agree that a history of at least two color changes (pallor and cyanosis) after cold exposure is necessary for diagnosis. The examiner stated this was not described in the service records regarding her feet. He concluded that symptoms of her feet after service cannot be related to her exposure during active service because the feet did not become symptomatic proximate to the cold exposure. As noted above, there was no proof her feet were numb, cold, and changed color during active service. The examiner stated that the problem was increased sensitivity to cold weather due to the Veteran's own abnormal neural signals, circulation hormones, and mediators from the circulating cells and blood vessels. In other words, it was not the cold exposure during service that caused her exaggerated response. After having carefully reviewed the evidence of record, the Board finds that the preponderance of the evidence is against entitlement to service connection for Raynaud's phenomenon of the bilateral feet. Although she has a current diagnosis of Raynaud's phenomenon of the bilateral feet, the existing medical evidence does not show that this condition was manifested in service, or is otherwise related to service. The Veteran's service treatment records are completely unremarkable for any relevant complaints, treatment, or diagnosis of Raynaud's phenomenon of the feet or symptoms of cold injury residuals or Raynaud's phenomenon to the feet. While the Veteran's service treatment records did note a cold weather injury and possible Raynaud's diagnosis, they were in reference to the Veteran's complains of tingling and pain in her fingers and hands; no similar complaints were made in reference to her feet. Further, her May 1986 Medical Board examination was equally unremarkable for any indication of this condition or attendant symptoms. While the service treatment records did note foot pain, it was in reference to pain in the arch of the foot and a diagnosis of pes planus. (The Board notes that the Veteran was awarded service connection for this specific condition (pes planus) in a December 2011 rating decision.) There is no objective indication of Raynaud's phenomenon of the feet while she was in service. The Board notes that the Veteran had the thought process to report pain and tingling in her hands and fingers and cold weather injury to her hands at the time of the injury, subsequent to the injury, and at service discharge. Her allegation that she was unaware that the examiners failed to document her complaints regarding her feet is not credible, as it does not make sense for an examiner to hear complaints involving the hands/fingers and feet/toes and only document the hands/fingers because, as alleged by the Veteran, they were worse than the feet/toes. The multiple service treatment records providing documentation regarding the hands is indicative of the fact that only the hands were involved. For example, in February 1985, the examiner noted that a 25-year-old female complained of "painful hands after running [physical training] this [morning]." The examiner added that, "P[atien]t states that while she was running her fingers went numb and then her left hand went numb and distal forearm." Thus, the Veteran reported symptoms involving her hands and forearm. An April 1986 service treatment record shows the examiner wrote that the Veteran complained of a subjective history of pain in both hands with exposure to cold weather. In a May 1986 Report of Medical History completed by the Veteran at that time, she was asked if she had ever received or whether there was a pending claim for compensation for an existing disability, and she handwrote, "cold weather injury to hands." She reported a medical history involving the feet, which was noted to pertain to right plantar pain. An August 1986 service treatment record shows the examiner wrote that the Veteran "developed some pain in hands when temp[erature] decreased." In her February 1987 original claim for compensation benefits, when asked the nature of sickness, diseases, or injuries for which the claim was being made, the Veteran wrote, "Cold weather injury to both hands." See VA Form 21-526, Veteran's Application for Compensation or Pension, at item # 6. The Board finds that had the Veteran sustained an injury to her feet due to cold weather conditions at the same time she sustained cold weather injuries to her hands, she would have reported it at one point during the service. It is not logical that if the Veteran sustained an injury to her feet at the same time she sustained an injury to her hands, that only the hand injury would be documented. Again, when she had the opportunity to report what her disability was, she addressed the hands only. Id. The Board finds as fact that the Veteran did not sustain the cold injury to her feet at the same time she sustained the cold injury to her hands. See Kahana v. Shinseki, 24 Vet. App. 428, 440 (2011) ("[T]he Board may use silence in the [service medical records] as contradictory evidence only if the alleged injury, disease, or related symptoms would ordinarily have been recorded in the [service medical records]." citing to Fed.R.Evid. 803(7) (the absence of an entry in a record may be evidence against the existence of a fact if such a fact would ordinarily be recorded).). As an aside, the Board finds that the service treatment records are complete. This is probative evidence against the finding that the Veteran had Raynaud's phenomenon of the feet or symptoms of such diagnosis (to include symptoms of a cold injury) as a direct result of disease or injury incurred in or aggravated by her military service. See Struck v. Brown, 9 Vet. App. 145 (1996). The Board is aware that at the time of the April 1987 VA examination, the Veteran included her feet when asked about her present complaint. See VA Form 21-2545, Report of Medical Examination for Disability Evaluation, at item # 17. However, what must be noted is that the examiner physically examined and feet and found them to be, "Normal." Id. at item # 41.D. Beginning in 1996, the Veteran then reported that her feet were involved. See January 1996 VA treatment record. However, when she was seen in June 1998 by a private physician, she addressed her hands only. For example, in the "Orthopedic Report," the examiner wrote, "This 38-year-old woman was referred to this office on June 30, 1998 for evaluation for a condition that she has been diagnosed with relating to frost bite. She apparently had developed such a condition while in the military while in Germany and has had problems with her hands ever since." The examiner examined her hands only, as that was the only part she described was impacted by the frost bite. This is yet further evidence that the Veteran's feet were not impacted by frost bite in service. At the June 1999, February 2000, October 2003, August 2010, and April 2011 VA examinations, the Veteran reported having residuals of cold injury to her feet since service discharge. However, the Veteran has failed to provide any objective indication of Raynaud's phenomenon until the August 1998 private treatment record noting a Raynaud's diagnosis, more than ten years after her military service ended. Additionally, when she underwent pulse volume recording testing in February 2000, the report for the upper extremities showed findings that were consistent with Raynaud's disease; however, the testing for the lower extremities showed no evidence of a vasospastic disorder. This is evidence against a finding of Raynaud's more than 10 years following service discharge. The lapse of so many years after her separation from service and the first documented suggestion of this claimed disorder (Raynaud's phenomenon of the feet) is also probative evidence to be considered in determining whether this claimed disability may be traced back to her military service. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). As to evidence of a nexus to service, the Board finds that the evidence against a nexus outweighs the evidence that supports a nexus. In an October 2003 VA examination report, the examiner wrote that the Veteran had history of cold injury "most likely secondary to her time in Germany." The Veteran claims that this is evidence of a nexus to service. However, this examiner provided no rationale for her opinion. The Board finds as fact that the Veteran did not complain of a cold injury to her feet during service because there was no injury to her feet. See Kahana, 24 Vet. App. at 440. The examiner did not state the body parts involved in the "history of cold injury." However, even if the examiner implied that the feet were involved, the Board rejects that fact and any medical opinion based on that fact is accorded no probative value. See Reonal v. Brown, 5 Vet. App. 460, 461 (1993). Contrast the August 2003 opinion with the April 2011 VA examination report. There, the VA examiner stated that numbness and pain in the feet claimed as residuals of cold injury of the lower extremities was less likely than not caused by or a result of cold exposure during active service. The examiner noted that the Veteran had signs of Raynaud's in her hands while in active service, but not in her feet, which fact the Board finds is accurate. There was no record of pain, numbness, and tingling of her feet in the service treatment records; she did not complain of problems with her feet until 1998 per review of the claims file. The examiner noted that the literature states that a history of at least two color changes (pallor and cyanosis) after cold exposure is necessary for diagnosis. This was not described in the service records regarding her feet. He stated the symptoms of her feet after service could not be related to her exposure during active service because the feet did not become symptomatic proximate to the cold exposure. Her problem was increased sensitivity to cold weather due to her own abnormal neural signals, circulation hormones, and mediators from the circulating cells and blood vessels. In other words, it was not the cold exposure during service that caused her symptoms. The Board accords this medical opinion high probative value, as the examiner provided a detailed rationale for the opinion. As such, entitlement to service connection on a direct basis is not warranted. The Board is aware that the examiner neglected to address the one 1987 report involving her feet and that she began regularly reporting her feet being involved in 1996 and not 1998. The Board does not find that this impacts the medical opinion, as the Board finds as fact that the Veteran's feet were not involved when her hands were frostbitten. Thus, the examiner's conclusion of no frostbite in service is an accurate fact. Additionally, the Veteran's feet were physically examined by a medical professional in April 1987, and they were found to be normal. Therefore, the VA examiner's opinion would not be impacted by a negative clinical finding, since in his mind he believed there were no symptoms at that time. In other words, the examiner's opinion is based on accurate facts of there being no symptoms involving the feet until many years following service discharge. For theses reasons, the Board concludes that there is no prejudice to the Veteran in the VA examiner's use of the 1998 date as being when she first began reporting her feet were involved. The Board has carefully considered whether entitlement to service connection on a presumptive basis is warranted, as Raynaud's is a chronic disease, where service connection may be granted if it is manifested to a compensable degree within one year following service discharge. See 38 U.S.C.A. § 1101 (West 2002); 38 C.F.R. §§ 3.307, 3.309. However, the Veteran's feet were examined in April 1987 at the time of the VA examination and were found to be normal. The Board accords this VA examination report high probative value, as the examination was conducted contemporaneously following service. After the 1987 VA examination, the Veteran did not receive treatment for her feet until 1996. Regardless, it must be noted that February 2000 testing showed Raynaud's in the upper extremities but failed to show such in the lower extremities, which further supports the finding that the disease process was not manifested to a compensable degree within one year following service discharge. The VA examiner's opinion is based on review of the claims folder, including the Veteran's service treatment records, and his opinion thoroughly discusses the Veteran's pertinent in-service and post-service medical records. The VA examiner offered a detailed explanation of the rationale for the opinion that incorporates both the facts of the Veteran's case and the pertinent medical principles. Given the VA examiner's access to the claims folder and the thoroughness and detail of his opinion, the Board finds this opinion to be more probative than the Veteran's assertions that Raynaud's phenomenon of the bilateral feet is due to service. Again, her allegation that her feet were injured at the same time is rejected as not credible. In reaching the decision above the Board considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against entitlement to service connection for Raynaud's phenomenon of the bilateral feet, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for Raynaud's phenomenon of the bilateral feet is denied. ____________________________________________ Alexandra P. Simpson Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs