Citation NR: 9738619 Decision Date: 11/19/97 Archive Date: 12/02/97 DOCKET NO. 96-20 138 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston- Salem, North Carolina THE ISSUE Entitlement to service connection for peripheral vascular disease as secondary to the service-connected disability of epidermatophytosis of the feet with history of trench foot. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant, H.C. ATTORNEY FOR THE BOARD W. R. Steyn, Associate Counsel INTRODUCTION The veteran had active military service from January 1943 to January 1946. This claim arises before the Board of Veterans’ Appeals (Board) from an October 1995 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO), which denied the veteran’s claim seeking entitlement to service connection for peripheral vascular disease as secondary to the service connected disability of epidermatophytosis of the feet with a history of trench feet. In the October 1995 rating decision, the RO also denied an increased rating for epidermatophytosis of the feet with a history of trench foot from 10 percent disabling. However, the veteran did not indicate that he disagreed with that decision and thus it is not before the Board at this time. The veteran originally indicated that he wished to have a hearing before the Board, but in an August 1996 letter indicated that he no longer wanted such a hearing. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends, in essence, that his peripheral vascular disease of the feet is related to his service- connected disability originally described as bilateral trench foot with epidermatophytosis. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991 & Supp. 1996), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that entitlement to service connection for peripheral vascular disease of the small arteries of the feet as secondary to the service-connected epidermatophytosis of the feet with a history of trench foot is granted. FINDINGS OF FACT 1. All relevant evidence for an equitable disposition of the veteran’s appeal has been obtained. 2. The veteran’s peripheral vascular disease of the small arteries of the feet (toes) is proximately due to the epidermatophytosis of the feet from service. 3. The veteran’s peripheral vascular disease at other locations in his lower extremities is related to his diabetes mellitus and smoking history. CONCLUSION OF LAW Service connection for peripheral vascular disease of the small arteries of the feet secondary to the service-connected epidermatophytosis of the feet with history of trench feet is warranted. 38 U.S.C.A. § § 1110, 5107 (West 1991); 38 C.F.R. § 3.303, 3.310 (a) (1996). REASONS AND BASES FOR FINDINGS AND CONCLUSION Background Service medical records show that in June 1943, the veteran was treated for athlete’s foot and ointment was prescribed. In December 1944, the veteran was treated for very mild bilateral trenchfoot. At the veteran’s separation examination in January 1946, his feet were evaluated as normal. The veteran did not report any physical complaints. By a rating decision of April 1960, the RO granted service connection and assigned a 10 percent rating for bilateral trench foot with epidermatophytosis. By a rating decision of January 1984, the Board denied an increased rating for epidermatophytosis of the feet with a history of trench foot from 10 percent disabling. The veteran was afforded a VA medical examination dated April 1990, a copy of which has been associated with the claims folder. The veteran complained of painful feet and legs when walking and cramps in both legs. Diagnosis was very poor circulation of both feet and legs. VA outpatient treatment records from September 1990 to November 1990 were submitted. In September 1990, the veteran indicated that he had increasing pain in his feet which was probably related to his circulation. Assessment was that the veteran’s dermatophytoses and onychomycosis was doing reasonably well and he continued to excoriate his skin. He was advised to apply Lotrimin liquid, Bactaban ointment, and GI foot powder to his feet. On another outpatient visit in September 1990, the veteran’s femoral pulses were present bilaterally, but his dorsalis pedis and posterior tibial vessels were both not palpable. Assessment was peripheral vascular disease with loss of posterior tibials and dorsalis pedis bilaterally, and hammertoe deformity of the fourth and fifth toes bilaterally. VA outpatient treatment records from November 1992 to November 1994 were submitted. In November 1992, the veteran was seen and had minimal hyperkeratotic changes of the feet. Assessment was that the veteran’s dermatophytosis had improved. He was advised to apply Bactroban, GI powder, and Lotrimin liquid. The veteran was seen in January 1993 and it was noted that the soles and interdigital areas of his feet were improved. Assessment was that the veteran’s dermatophytosis had improved. The veteran was advised to continue using Bactroban ointment and GI foot powder. He was advised to rotate his shoes and to apply maximum ventilation to his feet at all times. The veteran was seen in March 1993 and the interdigital areas of his feet and soles appeared “quite good”, although it was noted that the continued to exhibit dystrophic toenails. Assessment was improved dermatophytosis with continued excoriation of the skin. It was noted that the veteran was trying to get his blood sugar reduced. Application of Mycelex cream and GI powder were advised. When the veteran was seen in September 1993, it was noted that the dermatophytosis of both feet was improved. Bactraban ointment was recommended. When the veteran was seen in November 1993, it was noted that the veteran’s dermatophytosis with onychomycosis seemed to be doing “quite well”. Mycelex cream and GI powder were to be continued. The veteran was afforded a VA medical examination dated August 1995, a copy of which has been associated with the claims folder. The veteran indicated that his feet burned and hurt, especially his left foot and leg. His legs seemed weak and went out on him easily. Examination of the skin showed minimal dematophytic infestation of both feet with moderate onychomycosis of the toenails of both feet. The feet were warm. There was no excess moisture. There were no sores. The veteran had superficial abrasions of the type that would be due to bumping into things, compounded by age and diabetes. None of the abrasions seemed to be infected or to be of any significant problem at the time of the examination. Examination of the cardiovascular system showed that the heart was not enlarged and no murmurs were heard. The feet were warm. The Collins oscillometer showed deflection of one unit on the left ankle and slightly less than one unit on the right ankle. Diagnoses showed somewhat impaired circulation of both lower extremities, history of frostbite, onychomycosis, and dermatophytosis. The veteran was afforded a personal hearing dated July 1996, a transcript of which has been associated with the claims folder. The veteran testified that he was originally hospitalized in service for at least five days when his feet were frozen. He described having problems with his feet about a year or two after service. He described seeing Dr. Griggs after service for his frostbite, and indicated that he saw him for about 15 to 20 years. Dr. Griggs reportedly found the diabetes as a side result of treating his feet. The veteran testified about his service connected foot condition and how it affected him. He described not being able to stand up sometimes in the morning. He testified that his feet gave out on him and that he fell sometimes. He also indicated that he had to exercise and rub his feet. He indicated that a Dr. Tabor told him that poor circulation caused him to fall. The veteran indicated that his feet hurt in his heel and the bottom of his feet and the top of his big toe of his left foot. He indicated that he wore specially built shoes with ventilating holes in them. He also indicated that he was being treated for a fungus of his toenails. The veteran related that he had seen about 6 to 7 foot doctors who all told him that the frostbite caused the poor blood circulation in his feet and legs. The doctors reportedly told him that all they could do was to prescribe blood circulation tablets and medicine for his feet. The veteran asserted that he wished his claim to be described as a peripheral vascular disease of all of the lower extremities and not just the feet. VA x-ray reports were submitted from June 1995 and September 1995. Impression was calcaneal spurs bilaterally and some degree of osteoporotic changes involving the digits bilaterally. VA outpatient treatment records were submitted from December 1994 to June 1996. Assessment on June 7, 1995 was peripheral vascular disease with infected lesions of the left leg. On July 17, 1995 the veteran was seen and examination of the lower extremities showed that they had no palpable pulses. Assessment was Type II diabetes mellitus with blindness and peripheral vascular disease. Assessment on September 6, 1995 was infected left leg. Assessment on December 6, 1995 was heel spurs, probably bilateral with probable hammertoe deformity bilateral and itching of the left with numerous deep excoriations and crusting. Examination on March 13, 1996 showed that pulses were not palpable in both the posterior tibials and the dorsalis pedis arteries, bilaterally. Assessment was frost bite of the feet with burning sensation, which was much worse recently. Assessment on March 30, 1996, was tinea pedis with onychomycosis. At a podiatry examination on April 25, 1996, assessment was diabetes mellitus with peripheral vascular disease. On June 26, 1996, the veteran was seen again and examination of the blood vessels of the lower legs revealed that the pulses in the posterior tibials and the dorsalis pedis arteries bilaterally were absent. Assessment was history of frozen feet with poor circulation to the lower extremities, diagnosed as peripheral vascular disease secondary to frozen feet. In a statement dated October 1996, the veteran’s representative indicated that Dr. Tabor, the veteran’s primary care physician at the VA, stated that it was his medical opinion that the veteran’s circulation disorder was caused by frozen feet. He also indicated that a VA dermatologist said that the veteran’s circulation problems were due to his diabetes. He also asserted that the veteran testified at his hearing that his symptoms of leg discomfort and pain preceded his diagnosis as a diabetic. In a statement dated November 1996, a VA podiatrist indicated that the veteran had told him that he had a history of frozen feet from World War II with resultant poor circulation to the feet with a long history of diabetes mellitus. Examination showed that dorsal pedis and posterior tibial anterior pulses were absent in the feet. Popliteal artery pulses were weak. The examiner indicated that the veteran wore prescription molded shoes and had burning paresthesias of the lower extremities. The veteran’s claim was initially before the Board in September 1997, from where an expert medical opinion was requested from the VA Medical Center in Boston, Massachusetts. In October 1997, the expert medical opinion was obtained from the VA Medical Center in Boston, Massachusetts. After reviewing the records, the examiner indicated that the veteran had painful feet present since his frostbite injury in World War II and from periodic compensation examinations since April 1960. The examiner provided several assessments, including arterial occlusive disease at the right and left superficial femoral arteries most likely related to his diabetes mellitus and his smoking history and arterial occlusive disease at the small arteries of his feet (toes) probably related to the cold immersion injury (frostbite) that he sustained in World War II and which contributed to his chronic pain and discomfort. The examiner also indicated that the associated nerve damage from the frostbite also increased his risk for injury and infections of his feet, and an increased risk of amputation. The examiner opined that the veteran’s cold injury in World War II caused an injury to the vascular endothelial cells of his feet which subsequently led to premature occlusive changes in these vessels. The examiner indicated that smoking and diabetes also contributed to those changes in the foot vessels. Analysis As a threshold matter, the Board notes that the veteran’s claim for entitlement to service connection for peripheral vascular disease secondary to the service-connected epidermatophytosis of the feet with history of trench foot is well grounded within the meaning of 38 U.S.C.A. § 5107(a) (1991). That is, he has presented a claim which is plausible. The Board is satisfied that all relevant facts with respect to the veteran’s claim have been properly developed and no further assistance to the veteran is required to assist him, as mandated by 38 U.S.C.A. § 5107(a). Under the applicable law and VA regulations, in order to establish service connection, the veteran must submit objective evidence that establishes that his current disability is the result of a disease or injury that either began in or was aggravated by service. 38 U.S.C.A. § 1110. (1991). A disability which is proximately due to or the result of a service-connected disease or injury shall be service- connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310 (a) (1997). As discussed above, the veteran was diagnosed on several occasions with peripheral vascular disease when he was provided with VA outpatient treatment. In July 1995, the veteran was assessed with Type II diabetes mellitus with blindness and peripheral vascular disease. In July 1996, the veteran was assessed with history of frozen feet with poor circulation to the lower extremities, diagnosed as peripheral vascular disease, secondary to frozen feet. The veteran is not entitled to service connection for peripheral vascular disease on a direct basis, as there is no evidence in the service medical records of peripheral vascular disease or related symptomatology. However, under 38 C.F.R. § 3.310 (a), if the evidence shows that the veteran’s peripheral vascular disease is proximately due to or the result of his service-connected epidermatophytosis of the feet with a history of trench foot, then the veteran is entitled to service connection for his peripheral vascular disease on a secondary basis. As noted earlier, the veteran’s claim was sent for an expert medical opinion to a VA medical center in September 1997, specifically to discern the etiology of the veteran’s peripheral vascular disease. The examiner reported in October 1997 that the evidence showed that the veteran had arterial occlusive disease at the small arteries of his feet (toes), probably related to the cold immersion injury (frostbite) that he sustained in World War II, and also arterial occlusive disease at the right and left superficial femoral arteries, most likely related to his diabetes mellitus and his smoking history. While the examiner concluded that the veteran had arterial occlusive disease, he concluded that the veteran’s arterial occlusive disease at the small arteries of his feet was due to his cold immersion injury and that the arterial occlusive disease at the right and left superficial femoral arteries was most likely related to his diabetes mellitus and his smoking history. This distinction the examiner drew between the etiology of the arterial occlusive disease at different sites in the lower extremities, with the etiology of the arterial occlusive disease at the small arteries of the feet (toes) being due to his cold immersion injury, supports the proposition that the veteran’s peripheral vascular disease at the small arteries of the feet is due to his service- connected disability and that any type of other vascular disease at other locations in his lower extremities is more attributable to his diabetes and smoking history. The Board finds that the evidence is approximately in equipoise with regard to the question of whether the veteran’s peripheral vascular disease at the small arteries of the feet (toes) is proximately due to or the result of his service-connected epidermatophytosis of the feet with a history of trench foot. Granting the veteran the benefit of the doubt, in view of the fact that the veteran currently has a diagnosis of peripheral vascular disease, and the expert medical opinion linked his “arterial occlusive disease at the small arteries of his feet (toes)”, with his cold immersion injury from World War II, the evidence establishes that the veteran’s peripheral vascular disease at the small arteries of the feet (toes) is proximately due to or the result of his service-connected disability. Thus, the grant of service connection is warranted for peripheral vascular disease at the small arteries of the feet (toes), as secondary to the service-connected epidermatophytosis of the feet with history of trench foot. ORDER Entitlement to service connection for peripheral vascular disease at the small arteries of the feet (toes), as secondary to the service-connected epidermatophytosis of the feet with history of trench foot is granted. G.H. SHUFELT Member, Board of Veterans' Appeals NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991 & Supp. 1997), a decision of the Board of Veterans’ Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans’ Judicial Review Act, Pub. L. No. 100-687, § 402, 102 Stat. 4105, 4122 (1988). The date that appears on the face of this decision constitutes the date of mailing and the copy of this decision that you have received is your notice of the action taken on your appeal by the Board of Veterans’ Appeals. - 2 -