Citation Nr: 22014291 Decision Date: 03/12/22 Archive Date: 03/12/22 DOCKET NO. 09-39 662 DATE: March 12, 2022 ORDER Entitlement to service connection for a right lower extremity peripheral nerve disability, to include as secondary to service-connected tinea pedis with onychomycosis, for accrued benefits purposes is denied. FINDING OF FACT The Veteran's right lower extremity peripheral nerve disability was not shown in service or within a year of separation from service, was not continuous since service, and is not etiologically or causally related to service; it is not proximately due to and/or aggravated by his service-connected tinea pedis with onychomycosis. CONCLUSION OF LAW The criteria for entitlement to service connection for a right lower extremity peripheral nerve disability, to include as secondary to service-connected tinea pedis with onychomycosis, for accrued benefits purposes have not been met. 38 U.S.C. §§ 1110, 1112, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from September 1968 to November 1969, to include service in the Republic of Vietnam. The Veteran died in April 2015. The appellant is the Veteran's surviving spouse. The appellant has been appropriately substituted for the Veteran for the purpose of seeking accrued benefits based on his claim that was on appeal at the time of his death. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified in a personal hearing before a Decision Review Officer (DRO) in February 2009. The hearing transcript is associated with the file. In January 2015, the Veteran requested a videoconference hearing. In March 2015, the Veteran requested a hearing in Washington, D.C. In February 2017, after the Veteran's death, the appellant withdrew the request for a hearing The Board remanded this issue in March 2014, April 2015, October 2017, March 2021, July 2021, and September 2021 for further development. A review of the record shows substantial compliance with the Board's remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Entitlement to service connection for a right lower extremity peripheral nerve disability, to include as secondary to service-connected tinea pedis with onychomycosis, for accrued benefits purposes. The Veteran asserted that his right lower extremity nerve disability is related to his tinea pedis with onychomycosis. He claimed that the tinea pedis on his feet caused sores and rashes and made the simple task of walking unbearable. The sores and rashes affected his gait, as he frequently had outbreaks. It affected his ability to walk normally and maintain proper posture. Further, the Veteran stated that he was involved in a vehicle crash and suffered an injury that day which manifested itself later. The Veteran stated that he had leg pain since 1992. See October 2009 VA Form 9 and January 2015 Correspondence. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). 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. 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Secondary service connection may be granted for a disability that is proximately due to, or aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310. In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). A disorder diagnosed after discharge may be service connected if all the evidence establishes that the disorder was incurred in service. 38 C.F.R. § 3.303(d). Certain chronic diseases, to include organic diseases of the nervous system, may be service-connected on a presumptive basis if manifested to a compensable degree within a specified period of time following separation. 38 U.S.C. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). With a chronic disease shown as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent cause. For the showing of chronic disease in service, there is a required combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). Here, service treatment records are silent for any signs, symptoms, complaints of, treatment for, or diagnosis of right lower extremity peripheral neuropathy or a right leg condition. For example, on his May 1968 Report of Medical Examination (pre-induction), the Veteran's neurologic condition and lower extremities were evaluated as normal. On his October 1969 Report of Medical Examination for separation, the Veteran's neurologic condition and lower extremities were also evaluated as normal. On his October 1969 Report of Medical History for separation, the Veteran stated that he was in good health and did not check "yes" to having any medical conditions. Additionally, VA treatment records show that his right lower extremity neuropathy problems did not start until many years after service. Although the Veteran stated that he injured his right leg in service, the Veteran stated that he experienced leg pain since 1992. The diagnosis date on his June 2014 VA examination for his right nerve palsy was 2005. The Veteran did not start having symptoms until many years after service. Thus, as the evidence shows that the Veteran's disability did not have its onset in service, the claim turns on whether the post-service disability is related to service. Next, the Board will address the numerous medical opinions of record to determine whether a nexus exists between the Veteran's military service and his right lower extremity peripheral nerve disability and whether the Veteran's right lower extremity peripheral nerve disability is secondary to his service-connected tinea pedis with onychomycosis. The Board finds that there is no positive medical opinion of record in favor of the Veteran's claim. Turning to the evidence of record, in June 2014, a VA examination was performed on the Veteran. The Veteran was diagnosed with right nerve (common peroneal nerve) palsy. The diagnosis date was noted to be 2005. The VA examiner opined that the Veteran's claimed condition was less likely than not incurred in or caused by his military service. There was no evidence of any spondylosis seen while the Veteran was active. The actual symptoms in the Veteran were secondary to lumbar severe spondylosis with canal stenosis. This was causing bilateral leg numbness and claudication (stenosis was causing the vast majority of the symptoms, such as claudication). This was an aging condition not related to traumas (is a degenerative joint disease in the spine). Also, the VA examiner opined that the Veteran's condition was less likely than not proximately due to or the result of the Veteran's service-connected condition. Tinea pedis did not cause or aggravate any neurological condition. Tinea pedis was a dermatological condition that did not affect the peripheral nerves. In May 2020, a VA addendum medical opinion was obtained. The VA examiner opined that the Veteran's right leg peripheral nerve disability was less likely than not incurred in or caused by the Veteran's military service. The VA examiner stated that after the evaluation of the medical records and lay statements, it was his opinion that the Veteran's right leg nerve disability was less likely than not related to service. There was no evidence of any right leg neurological symptoms seen related to any accidents, traumas, or physical activities. Symptoms had an onset years after service. The Veteran's symptoms were attributed to right leg length discrepancy as well as to several lumbar conditions seen in an MRI done in 2008. The Veteran had severe lumbar stenosis as well as severe foraminal stenosis from L4/L5 bilaterally, which could be causing (besides a right leg neuropathy) a right leg radiculopathy. These conditions were not service related but related mainly to the aging process. The Veteran's condition had tis onset years after service. The Veteran was offered a lumbar decompressive surgery, but he declined (in 2008/2009). Neither were these conditions related to any accidents, but to the aging process. The Veteran's tinea pedis and onychomycosis was less likely than not proximately due to or the result of the Veteran's service-connected condition. Tinea pedis with onychomycosis had nothing to do in terms of etiology or pathophysiology to the above mentioned conditions in the spine or in the peripheral nerves; they were not related. The VA examiner explained that baseline level of severity could not be determined because there was no evidence of neurologic right leg symptoms or deterioration during active service or a year thereafter. In April 2021, a VA addendum medical opinion was obtained for the Veteran's right lower extremity peripheral nerve disability. The VA examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. Tinea pedis was a superficial fungal infection that affected the skin on the feet and could spread to the toenails, medical literature did not describe an anatomic, biochemical, or physiologic mechanism for a superficial fungal infection to affect the peripheral nerves. Medication taken for tinea pedis (ketoconazole cream) was a topical medication, which was not absorbed systemically and could not affect peripheral nerves. The April 2021 VA examiner further opined that the Veteran's right lower extremity peripheral neuropathy was less likely than not proximately due to or the result of the Veteran's service-connected tinea pedis. Tinea pedis was a superficial fungal infection that affected the skin on the feet and could spread to the toenails, medical literature did not describe an anatomic, biochemical, or physiologic mechanism for a superficial fungal infection to affect the peripheral nerves. Medication taken for tinea pedis (ketoconazole cream) was a topical medication, which was not absorbed systemically and could not affect peripheral nerves. Further, medical literature and review of the medical record (and service treatment records) did not support a physiologic, biomechanical, or anatomic mechanism for tinea pedis, to include medications to cause or permanently aggravate right peripheral nerve condition beyond its natural progression. The Veteran's peripheral nerve condition was caused by the Veteran's lumbar stenosis, which was the source of the Veteran's limp, not a superficial fungal infection. In August 2021, a VA addendum medical opinion was obtained. The VA examiner opined that it was less likely than not that the Veteran's right lower extremity peripheral nerve condition was incurred in or caused by the Veteran's claim in-service injury, event, or illness. The VA examiner explained that the Veteran's lower extremity peripheral neuropathy disability did not have its onset during service. The separation examination was negative for peripheral neuropathy of the lower extremity. The temporal pattern of the Veteran's peripheral neuropathy did not fit with it being incurred or caused by service or by the claimed in-service accident. The gaps in time from his service period until the diagnosis of the peripheral neuropathy were not consistent with the natural history and development of the condition. Traumatic injury to a nerve would have acute symptoms and would not develop years after the incident. Thus, it was less likely than not (less than 50 percent probability) that the Veteran's lower extremity peripheral nerve disability had its onset during service or was related to his active service, to include the claimed in-service car accident. The August 2021 VA examiner further opined that the Veteran's right lower extremity peripheral neuropathy was less likely than not proximately due to or the result of the Veteran's service-connected tinea pedis with onychomycosis. These conditions were not medically related. The peripheral neuropathy of the right lower extremity was a separate entity entirely from the tinea pedis with onychomycosis and unrelated to it. The peripheral neuropathy of the right lower extremity was unrelated to the tinea pedis with onychomycosis, or the topical medications used to treat the Veteran's tinea pedis with onychomycosis. The Veteran's peripheral neuropathy was not related to any gait deviations that might be caused by the service-connected disability. A thorough review of the medical literature failed to demonstrate a causal relationship. A nexus had not been established. Tinea pedis with onychomycosis was caused by an exposure to a fungus and an infection with a fungus and an infection with a fungus. The Veteran's service-connected tinea pedis with onychomycosis was an infection limited to the skin and toenails. The Veteran's peripheral neuropathy did not have an infectious etiology and was completely unrelated to the service-connected tinea pedis with onychomycosis. Complications of tinea pedis with onychomycosis did not include lower peripheral neuropathy. The medical literature did not describe an anatomic, biomechanical, or physiologic mechanism whereby tinea pedis with onychomycosis would cause this peripheral neuropathy. The topical medications used for his tinea pedis with onychomycosis had negligible systemic absorption, and thus could not cause his lower extremity peripheral neuropathy or aggravate it. The Veteran claimed discomfort from the tinea pedis caused him to limp. This would not have caused or aggravated the neuropathy as such a limp was unlikely to have directly or significantly affected the site of nerve entrapment involved in this neuropathy. Thus, the Veteran's right lower extremity peripheral neuropathy was less likely than not proximately due to his service-connected tinea pedis with onychomycosis, to include any medications used to treat the service-connected disability or due to any gait deviations that might be caused by the service-connected disability. Additionally, the VA examiner concluded that medical literature also failed to demonstrate aggravation of the Veteran's peripheral neuropathy from tinea pedis or the topical medications that were used in treatment for his tinea pedis. A nexus for aggravation was not established. As for the claimed discomfort from the tinea pedis with onychomycosis causing the Veteran to limp, this would not have caused or aggravated the neuropathy as such a limp was unlikely to have directly or significantly affected the site of entrapment involved in this neuropathy. Tinea pedis with onychomycosis and the Veteran's peripheral neuropathy were two separate and distinct conditions. The topical medications used for the Veteran's tinea pedis with onychomycosis had negligible systemic absorption and would not be an aggravating factor in his lower extremity peripheral neuropathy. Thus, it was less likely than not that the Veteran's right lower extremity peripheral nerve disability was aggravated by his service-connected tinea pedis with onychomycosis, to include any medications used to treat the service-connected disability or any gait deviations caused by the service-connected disability. In October 2021, the Veteran was afforded a VA examination for his right lower extremity peripheral disability. The VA examiner opined that the Veteran's right lower extremity peripheral neuropathy was less likely than not proximately due to, the result of, and/or aggravated by his service-connected tinea pedis and onychomycosis. The VA examiner explained that being superficial fungal infections in the feet/toes, they did not directly impact the peroneal nerve (which itself was proximal to the feet and toes, running its course from between the knee and ankle), nor cause neuropathy. Medications to treat the aforementioned service-connected conditions were topical with very limited absorption into the skin and would thus not affect the nerves. Furthermore, the peroneal nerve was proximal (upstream) of the toes and feet. Any potential nerve compression contributing to peroneal nerve symptoms would occur likewise proximal of the feet/toes (where the tinea pedis and onychomycosis occur) and would have to be along the peroneal nerve. Any potential compression of the peroneal nerve would thus not be affected by gait and change in biomechanics of the feet as they were above/proximal to the feet/toes. The VA examiner also gave this reasoning in response to the Veteran's lay statements that he had difficulty walking and maintaining proper posture due to frequent breakouts of sores and rashes on his feet from tinea pedis with onychomycosis. When all these medical opinions are read together as a whole, the Board finds that they are adequate and sufficient enough in detail to be probative in value and weigh against the appellant's claim for service connection on both a direct and secondary basis. These VA medical opinions take into account the Veteran's lay statements about his disability, consider the full medical evidence of record, and provide a thorough explanation as to why the Veteran's right lower extremity peripheral nerve disability is not related to his service, including claimed right leg injury, and why it is not caused or aggravated by his service-connected tinea pedis with onychomycosis. The Board has considered the Veteran's opinion that his right lower extremity nerve disability is related to his claimed right leg injury in service or secondary to his tinea pedis with onychomycosis. While he was competent to report symptoms that came to him through his senses, the evidence does not show that he possessed the requisite medical expertise for providing an opinion as to whether his post-service disability was related to an in-service injury or a service-connected disability. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Woehlaert v. Nicholson, 21 Vet. App. 456, 462. Such competent evidence has been provided by VA examination reports, the medical evidence, and by service treatment records obtained and associated with the claims file. Here, the Board attaches greater probative weight to the medical evidence and clinical findings than to the Veteran's statements. Moreover, as the Veteran served in the Republic of Vietnam during the Vietnam era, he is considered to have been exposed to herbicide agents. See 38 C.F.R. § 3.307. The Board acknowledges that early onset peripheral neuropathy is a disability related to Agent Orange exposure. See 38 C.F.R. § 3.309. However, there is no evidence or contention that the Veteran had early onset peripheral neuropathy. There is also no evidence of any relationship between the Veteran's peripheral nerve disability or Agent Orange exposure. Thus, the Board will not address this issue. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). In light of the above discussion, the weight of the evidence is against the claim for service connection on a direct and secondary basis. The evidence is not in approximate balance, and there is no doubt to be resolved. As such, service connection is denied. Joshua Castillo Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Crawford, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.