Citation Nr: 1332765 Decision Date: 10/21/13 Archive Date: 10/24/13 DOCKET NO. 08-15 563 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri THE ISSUES Entitlement to service connection for residuals of cold injury of the extremities. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD Suzie S. Gaston, Counsel INTRODUCTION The Veteran served on active duty from July 1970 to January 1972. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2007 rating decision, by the St. Louis, Missouri RO. In March 2010, the Board remanded the case to the agency of original jurisdiction (AOJ) for further evidentiary development. A supplemental statement of the case (SSOC) was issued in December 2011. In November 2012, the Board again remanded the case for further evidentiary development. Following the requested development, the VA Appeals Management Center (AMC) issued another SSOC in March 2013. A review of the record reflects substantial compliance with the Board's directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). FINDING OF FACT The Veteran experiences residual symptoms related to cold exposure during his period of active military service. CONCLUSION OF LAW The Veteran has residuals of a cold injury to the upper and lower extremities that was incurred in service. 38 U.S.C.A. §§ 1110, 1154, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran's military personnel records indicate that he served in Korea from January 1971 to February 1972; his military occupational specialty was as a field wireman. His service treatment records, including the February 1970 enlistment examination as well as the December 1971 separation examination, are devoid of any complaints of, treatment for or diagnosis of any cold weather injuries. The Veteran's claim of entitlement to service connection for residuals of cold injury of the hands and feet (VA Form 21-526) was received in April 2007. Submitted in support of the claim were VA progress notes dated from February 2007 to May 2008. These records reflect ongoing treatment for rheumatoid arthritis, which is an autoimmune process that can affect the joints, particularly those of the extremities. During a clinical visit in February 2007, it was noted that the Veteran was being seen for the first time and wished to transfer care from a private rheumatologist to the VA. The diagnosis was rheumatoid arthritis. During a consultation in March 2007, it was noted that the Veteran had been seeing Dr. C. J. for rheumatoid arthritis for about 10 years. Examination revealed swelling in the elbow, right greater than left. The diagnosis included rheumatoid arthritis, mildly active. An x-ray study in March 2007 reported an impression of wrist degenerative joint disease, old distal ulna trauma. On January 9, 2008, the Veteran was seen for complaints of diffuse joint pain. It was noted that the Veteran had a history of rheumatoid arthritis. The diagnoses were rheumatoid arthritis and foot pain, probably plantar fasciitis. An x-ray study, performed in January 2008, revealed an impression of degenerative arthritis of the right first metatarsophalangeal joint and plantar calcaneal spur. Of record is a rheumatology note, dated in October 2009, which indicates that the Veteran received treatment for complaints of pain in the shoulders, feet and ankle; he also complained of minimal morning stiffness but no swelling. The assessment was polyarthralgia, shoulders; and rheumatoid arthritis, mildly active. Received in April 2010 were VA progress notes dated from December 2009 to March 2010. These records show that the Veteran received ongoing clinical attention and treatment for rheumatoid arthritis. In December 2009, the Veteran was seen for injections in the shoulders; at that time, he reportedly was okay, except for some joint pain in the wrists, ankles, and minimal swelling in the fingers. He also reported some morning stiffness for 30 minutes. The assessment was joint pain, rheumatoid arthritis, and osteoarthritis of both shoulders, with history of rotator cuff injury. The Veteran was afforded a VA compensation examination for evaluation of cold injury in June 2010. It was noted that the Veteran was stationed in Korea in the Signal Corps and was exposed to cold temperatures, as low as minus 30 degrees, and wet and snow. The parts of the body affected were his hands, feet and cheeks. The Veteran indicated that his symptoms at the time of his cold injury were numbness of the fingertips, the toes, and the cheeks; he was treated by a medic. The Veteran related that he currently experiences sensitivity to cold below 32 degrees Fahrenheit. There has been no amputation of tissues. There was cold sensitization, but no Reynaud's phenomenon. There was hyperhidrosis. There was no paresthesia or numbness. There was no evidence of reflex sympathetic dystrophy. There were no recurrent fungal infections. There was no breakdown of ulcerations. There was no disturbance of nail growth. There was no skin cancer. He had arthritis and stiffness of the joints of the hands and the feet. There was no edema. There was no skin color changing. There was no thickening or thinning of the skin. There was cold sensitization for temperatures below 30 degrees. He did not have numbness, tingling, or burning. He had pain in the metaphalangeal joints of both hands and feet and all interphalangeal joints. His current treatment involved medication for rheumatoid arthritis. The examiner noted that the Veteran was 21 years of age at the time of the cold injury; he was in Chuncheon, Korea. The type of cold injury sustained was frostbite that affected his hands, feet and cheeks. He was exposed 3 hours a day, 5 days a week for 1 month. He became aware of the cold injury because of the pain in his hand. He had swelling and discoloration, without tissue loss. He had numbness and tingling of the toes, fingers, and cheeks. He was not relieved from duty. The symptoms lasted 3 to 4 hours after the cold exposure, and the injured parts returned to normal in about 3 hours. It was noted that the Veteran worked as a truck driver for 33 years after the cold injury; the cold injury affected his work. After military service, he elected to always work inside, either in a warehouse or in a truck. He had had no treatment since service. The Veteran believed that his cold injury was related to his rheumatoid arthritis. The major problem with his cold injury was cold sensitization and arthritis. The impression was cold injury and rheumatoid arthritis. The examiner stated that the literature was searched and the following noted: "when a history of frostbite was obtained in addition to the features of connective-tissue disorder occurred on 2 separate patients, and although this combination of circumstances is likely to occur only rarely and then in colder climate." The examiner concluded that it was his opinion that cold injury was not at least as likely as not the cause of rheumatoid arthritis. The Veteran was afforded another VA examination in January 2013. At that time, he reported spending one year in Korea during the winter of 1970-1971; he was assigned to a Signal Company. The Veteran also reported that he spent a lot of time outside stringing wires. The Veteran stated that it was very cold during the winter and the equipment was bad; as such, his feet and hands got very cold. The Veteran indicated that he was treated for frostbite of the feet and hands, with no blackening or ulcers at the time. Since that time, he has been unable to go out during cold weather. The Veteran noted that he experienced pain in his feet, with burning, stinging, tingling and some weakness; he reported similar symptoms in his fingers. It was noted that the Veteran hand no blisters or blanching of his digits; and he had no deformities. No fungal abnormalities were noted in the nails. It was also reported that the Veteran experienced stiffening of finger joints, toes and ankles in addition excess sweating feet. It was further noted that the Veteran had documented rheumatoid arthritis since before 2007 with VA documentation in his hands and feet since 2007. On examination, it was noted that the Veteran had arthralgia, cold sensitivity and numbness in his right and left hands. He had arthralgia, cold sensitivity, hyperhidrosis, numbness and locally impaired sensation in both feet. The examiner noted that x-ray studies revealed osteoarthritis in the hands and feet. The examiner stated that the claimed condition was at least as likely as not incurred in or caused by the claimed in-service injury, event or illness. The examiner stated that there is sufficient history provided by the Veteran now and in the past to have established a claim for cold injury in all extremities. The injury happened under likely circumstances and in a location conducive to extensive cold injury. The examiner explained that the symptoms of cold sensitivity, numbness, paresthesia, weakness, hyperhidrosis and stiffness of fingers and toes are all part of a recognized and accepted catalogue of sequelae and findings associated with and attributable entirely to cold injury. The examiner opined that it was therefore more likely than not that these enumerated findings were related to service-connected cold injury. The examiner further noted that the finding of rheumatoid arthritis complaints in this context are interesting and complex and add no further specificity to the above determination. The examiner sated that there was literature to show that development of immune mediated arthritis can be promoted by prior cold injury. The examiner stated that, here, rheumatoid arthritis could also have developed independently. In this case, there was evidence for rheumatoid arthritis; on the other hand, current physical examination showed little in the way of deformity, joint deviation or hypertrophy. The examiner stated that in this instance, it requires speculation to determine to what degree cold exposure caused rheumatoid arthritis which then added to accepted cold injury symptoms. Likewise, it required speculation to determine to what degree rheumatoid arthritis developed independently and modified cold injury related symptoms. The Veteran asserts that he experiences certain residual problems due to cold injury incurred during his military service. Service connection is warranted for disability "resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty." 38 U.S.C. §§ 1110, 1131. To establish compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"--the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Holton v. Shinseki, 557 F.3d 1362 (2009). Where there is a chronic disease shown as such in service or within the presumptive period under 38 C.F.R. § 3.307 so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however, remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). This rule does not mean that any manifestation in service will permit service connection. To show chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the disease identity is established, there is no requirement of evidentiary showing of continuity. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Certain chronic diseases, including arthritis, may be presumed to have been incurred during service if they become disabling to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. The Veteran can attest to factual matters of which he has first-hand knowledge, such as experiencing pain in service, reporting to sick call, being placed on limited duty, and undergoing physical therapy. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a lay person is competent to identify the medical condition (noting that sometimes the lay person will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer), (2) the lay person is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether the evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21. Vet. App. 303 (2007). When reviewing medical opinions, the Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). However, the Board may not reject medical opinions based on its own medical judgment. Obert v. Brown, 5 Vet. App. 30 (1993); see also Colvin v. Derwinski, 1 Vet. App. 171 (1991). In assessing medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). A medical opinion may not be discounted solely because the examiner did not review the claims file. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2009). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. By reasonable doubt is meant one that exists because of an approximate balance of positive and negative evidence that does not satisfactorily prove or disprove the claim. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. 38 C.F.R. § 3.102. Having considered all of the above evidence and resolving reasonable doubt in favor of the Veteran, the Board concludes that service connection is warranted for residuals of cold injury of the upper and lower extremities. Although a cold injury was not identified during service, the Veteran has presented credible evidence regarding his cold exposure. The record confirms that the Veteran served in Korea from January 1971 to February 1972, and his military occupational specialty was as a field wireman, an occupation that placed him in the outdoors and subject to the environment. Therefore, he was exposed to the cold weather. In addition, post-service clinical records clearly show that the Veteran has received treatment for residuals of a cold injury to the extremities. The June 2010 VA examination reported diagnoses of cold injury. And, in January 2013, the examiner reported a diagnosis of cold injury. There is, thus, competent evidence of a current disability. The question for consideration is whether his cold injury residuals are related to his period of active service and exposure to the cold weather in Korea. There are conflicting medical opinions on this point. Following the recent VA examination in January 2013, the VA examiner stated that that there is sufficient history provided by the Veteran now and in the past to have established a claim for cold injury in all extremities. The injury happened under likely circumstances and in a location conducive to extensive cold injury. The examiner explained that the symptoms of cold sensitivity, numbness, paresthesia, weakness, hyperhidrosis and stiffness of fingers and toes are all part of a recognized and accepted catalogue of sequelae and findings associated with and attributable entirely to cold injury. Although the competent and probative evidence is not unequivocal, it has nonetheless placed the record in relative equipoise. Here, the benefit-of-the-doubt rule applies and it may be concluded that the evidence supports a grant of service connection. 38 U.S.C.A. § 5107(b) (West 2002). ORDER Service connection for residuals of cold injury of the extremities is granted. ________________________________ MARK F. HALSEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs