BVA9500788 DOCKET NO. 93-04 571 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Wichita, Kansas THE ISSUES 1. Entitlement to service connection for a stress reaction of the legs. 2. Entitlement to service connection for degenerative arthritis of the cervical and lumbar spine. 3. Entitlement to service connection for hypoglycemia. 4. Entitlement to service connection for a positive tuberculin test. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Nancy R. Kegerreis, Associate Counsel INTRODUCTION The veteran served on active duty from July 1976 to March 1979. This matter comes before the Board of Veterans' Appeals (Board) from a February 1991 rating decision by the Department of Veterans' Affairs (VA) Regional Office (RO) in Wichita, Kansas, which denied service connection for a stress reaction of the legs, degenerative arthritis of the cervical and lumbar spine, hypoglycemia, and a positive tuberculin test. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends, essentially, that she suffered a stress reaction to her legs and feet in service which continues with residual disabilities to the present time and that this disorder is well documented by her service medical records. She further contends that the onset of her chronic back disability occurred in service and is presently demonstrated by loss of range of motion and evidence of degenerative changes in the lumbar and cervical spine. In addition, she alleges that she should be granted service connection for hypoglycemia and for a positive tuberculin test. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), 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 the veteran has not met the initial burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that her claims are well grounded. FINDINGS OF FACT 1. The veteran's legs and feet show no current manifestations of structural abnormality, except for residuals of a very recent navicular fracture of the left foot, which is not related to any incident in service. 2. Degenerative arthritis of the cervical and lumbar spine a number of years after service has not been medically linked to service. 3. The veteran does not have any disease associated with hypoglycemia and related to service. 4. A positive tuberculin test was not indicative of pulmonary tuberculosis in service and the veteran does not currently have tuberculosis. CONCLUSIONS OF LAW 1. The veteran has not submitted evidence of a well-grounded claim for service connection for a stress reaction of the legs. 38 U.S.C.A. §§ 1131, 5107(a), 7105(d)(5) (West 1991); 38 C.F.R. § 3.303 (1993). 2. The veteran has not submitted evidence of a well-grounded claim for service connection for degenerative arthritis of the cervical and lumbar spine. 38 U.S.C.A. §§ 1131, 5107(a), 7105(d)(5) (West 1991); 38 C.F.R. § 3.303 (1993). 3. The veteran has not submitted evidence of a well-grounded claim for service connection for hypoglycemia. 38 U.S.C.A. §§ 1131, 5107(a), 7105(d)(5) (West 1991); 38 C.F.R. § 3.303 (1993). 4. The veteran has not submitted evidence of a well-grounded claim for service connection for a positive tuberculin test. 38 U.S.C.A. §§ 1131, 5107(a), 7105(d)(5) (West 1991); 38 C.F.R. § 3.303 (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service connection means, essentially, that the facts, as shown by evidence, establish that a particular injury or disease resulting in disability was contracted in line of duty coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 U.S.C.A. § 1131 (West 1991). Service connection may be granted presusmptively for certain chronic diseases first manifested after service. If the disease is arthritis, it must have become manifest to a degree of 10 percent or more within one year. Tuberculosis must have become manifest to a degree of 10 percent or more within three years. See 38 U.S.C.A. § 1101 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (1993). Additionally, 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) (1993). Each disorder for which a veteran seeks service connection must be considered on the basis of evidence, including that shown by service medical records, and pertinent medical and lay evidence. 38 C.F.R. § 3.303 (a) (1993). In this case, the Board finds that the veteran has not submitted well grounded claims within the meaning of 38 U.S.C.A. § 5107(a) (West 1993). This section of Title 38 unequivocally places an initial burden on a claimant to produce evidence that a claim is well grounded or plausible. See Grivois v. Brown, 6 Vet.App. 136, 139 (1994); Grottveit v. Brown, 5 Vet.App. 91, 91 (1993); Tirpak v. Derwinski, 2 Vet.App. 609, 610-11 (1992). Absent a well-grounded claim, the Board has no duty to assist, and the claim must be dismissed. See 38 U.S.C.A. § 7105(d)(5); Boeck v. Brown, 6 Vet.App. 14, 17 (1993). For purposes of determining whether a claim is well grounded, all of the evidence of record is examined, not just that which has been specifically submitted to support a particular claim. See e.g., Sibley v. Derwinski, 3 Vet.App. 188 (1992); Proscelle v. Derwinski, 2 Vet.App. 629 (1992); Godwin v. Derwinski, 1 Vet.App. 419 (1991). I. Stress Reaction of the Legs The veteran's enlistment medical examination in November 1975 was negative as to any of the claimed disorders. In August 1976, she was noted to have multiple somatic complaints, including stress reactions of both feet, low back pain, and anxiety. A physical examination was normal. The diagnostic impression was anxiety secondary to acute adjustment reaction and stress reactions of the feet and muscle strain of the back. She was provided with a "Gel Boot" for both feet and put on physical profile. In September 1976, the veteran complained of nervousness, hearing problems, being bothered by loud noises, a stress reaction in both feet and legs, and painful shins, later diagnosed as "shin splints." In July 1977, she continued to have shin splints and was put on physical profile. In October 1977, she reported pain in climbing stairs, in running and in standing for long periods of time, and requested a permanent physical profile. It was noted that her boots had previously been corrected. The diagnostic assessment was that her overweight condition resulted in increased stress of the lower extremities. The treatment plan comprised diet therapy, an overweight program, and an exercise program. The veteran was instructed to stop smoking and to return to duty. Throughout the rest of her military service, the veteran had severe shin splints, requiring her to be given physical profiles allowing her to perform her duties with limitations and permitting her to perform physical training to tolerance. A Report of Medical History upon separation from service, dated in February 1979, noted a history of exercise-related leg and foot problems. The medical records are silent for any reported abnormalities of the legs and feet in the nature of shin splints after service. In November 1990, the veteran was afforded a VA physical disability evaluation examination, which noted a reported history of shin splints in basic training. She reported a history of bilateral knee discomfort for twelve years, notably worse upon climbing stairs, but with no locking or effusion. Physical examination showed a normal alignment, with full range of motion of both knees. The patellae tracks were normal, and there was no hypermobility, subluxation, crepitus, or pain with patellofemoral manipulation. The ligaments were stable, and there was no effusion and no popliteal cysts. The diagnosis was probable overload syndrome of the knees, no structural abnormality identified. Another VA disability evaluation in May 1992 noted a history of stress fracture, left foot, which had reportedly occurred in March 1992 while the veteran was in aqua-aerobics class. The fracture had been confirmed by bone scan, and the veteran was currently using a walking splint. Examination showed the feet to be normal to inspection and palpation and to have a normal range of motion and strength. The diagnosis was history of navicular fracture, left foot. In evaluating the veteran's claim for a stress reaction of the legs, the Board notes a discrepancy between the service diagnosis and the present diagnoses. In service, the veteran was found to have had shin splints due to obesity and strenuous physical activity. With treatment and limited physical activities, she continued her military service. The veteran's recent examinations, however, reveal that she currently has no discernible disorder of the legs or knees, other than a fracture of her left foot, which was incurred in March 1992, many years after service. The veteran's recent complaints of pain in the lower extremities have not been related to a disease entity. In any event, in the absence of medical evidence linking a current disability to stress reaction of the legs in service, the Board finds that the veteran's claim is not plausible, and, therefore, not well-grounded. See Rabideau v. Derwinski, 2 Vet.App. 141, 143 (1992). Accordingly, this claim must be dismissed. II. Degenerative Arthritis of the Cervical and Lumbar Spine The veteran's only report of back pain in service was in August 1978, when she noted a pain in her lower back after lifting a heavy radio. An examination demonstrated pain to palpation in the lower back, L5-S1, bilateral paraspinous spasm, and decreased range of motion, both on flexion and on extension. Deep tendon reflexes were equal bilaterally, and straight leg raising was negative. The clinical assessment was acute strain. The veteran was prescribed medications and confined to quarters for 24 hours. The records are silent as to a back disorder until March, April, and May 1984, when the veteran, who had married a serviceman, was treated by Army community clinics for low back pain. In May 1988, outpatient treatment records from Bill Braden, M.D., noted that the veteran had had lumbar pain since 1986. She had initially strained her back in the service lifting a radio. Then in 1986, she fell, hitting her cervical spine. She had been seeing a chiropractor with good results until recently. Dr. Braden's clinical records dated in June 1989 reveal that the veteran had started having low back pain three days prior to this office visit. Subsequently, an August 1989 record stated that she had fallen off her bed the day before, injuring her lower back and left ankle. Examination showed that her back was quite tender over the coccyx. Private x-rays in February 1989 and August 1989 found degenerative changes involving the lower thoracic spine, but no evident acute abnormality of the lumbar spine. A letter dated in November 1990 from John M. Wertin, D.C., provided diagnoses of chronic lumbar radiculitis from lumbar discopathy, recurrent cervical subluxation causing cephalgia. The veteran's prognosis was deemed to be guarded, as Dr. Wertin remarked that the disc deterioration in the lumbar spine was non- reversible and would worsen with age; it also directly contributed to a neck problem. The November 1990 VA disability evaluation examination, in noting a history relevant to the low back disorder, reported a heavy lifting injury in 1978 in service. The veteran had been treated with rest and medication, and the symptoms had improved. She then started having chronic low back pain during her second pregnancy. Currently, she complained that her low back pain became worse with prolonged standing, walking or lifting. An orthopedic consultation revealed a history of exacerbations of back pain across the sacral area. Following the lifting injury in service, the backache had become better. Then, with her first pregnancy, she had the "usual" backache, which improved postpartum. During her second pregnancy in 1986, she had trouble getting in and out of a car. Although there was no sciatic pain, her legs were reported to become numb when she walked a lot, and she could not sit or stand very long. Examination revealed a full range of motion of the left spine. There was no list or scoliosis. She was able to heel and toe walk, and a straight leg raising test was negative. There was a question of a slight thoracic scoliosis. The diagnoses were early degenerative arthrosis of the lumbar spine and degenerative disc disease of the C4-5 interspace. In March and December 1991, the veteran was again treated for low back strain. A March 1991 outpatient treatment report noted that although she had periodically had osteopathic and chiropractic manipulations, these only afforded temporary relief. The pain was located at the L4-5 area and was tender to palpation. There was no radiculopathy. A bone scan apparently revealed uptake in the L4-5 area on the right posterior lower rib cage. In December 1991, she was reported to have done "quite a bit" of lifting, which bothered her back. The May 1992 VA disability evaluation examination noted a history of degenerative joint disease of the cervical spine, which had first been diagnosed in 1987. The veteran reported that she had experienced symptoms of stiffness and discomfort with range of motion and that her symptoms had improved with Feldene. Examination showed a good range of motion of the cervical spine and the lumbosacral spine with mild discomfort. Reports of x- rays of the cervical spine and of the lumbosacral spine revealed degenerative changes in both areas. Pertinent diagnoses were degenerative joint disease of the cervical and lumbosacral spines, with chronic low back pain, and obesity. The above evidence reveals that although the veteran did sustain back strain in service, the injury apparently resolved following conservative treatment, as her February 1979 separation physical examination failed to report a chronic back disorder. Beginning in 1984 or 1986, she suffered repeated back strain , from an apparent fall, and from two pregnancies. In 1989, she again hurt her back in a fall. In reviewing the evidence, the Board is unable to find that the veteran's in-service injury resulted in a chronic disability in service. When there is insufficient evidence to establish that a claimed chronic disability was present during service, the evidence must establish a nexus, or relationship, between the veteran's current disability and service. In other words, there must be continuity of symptomatology. See Wilson v. Derwinski, 2 Vet.App. 16, 19 (1991). Here, the Board finds no evidence of continuity of symptomatology. Although the current diagnoses of degenerative joint disease of the cervical and lumbosacral spine do not suggest that the etiology of this disease was traumatic, even assuming for the sake of argument that they did, there is no evidence relating degenerative joint disease to the reported incident of back strain in service. Moreover, since 1984, the veteran has had repeated incidents of back strain due to events unrelated to service. In short, the veteran has not submitted evidence to show that arthritis of the cervical or lumbar spine is related to strain in service or otherwise linked to service. III. Hypoglycemia and a Positive Tuberculin Test Relative to the veteran's two remaining claims, the Board points out that both the alleged hypoglycemic reactions and the positive tuberculin test constitute symptomatology and not disease entities. Generally, for purposes of establishing service connection, the evidence must demonstrate that a particular injury or disease resulting in disability was incurred in or aggravated by service. A combination of manifestations sufficient to identify the disease entity is required unless a disease, such as tuberculosis, is actually identified in service. See 38 C.F.R. § 3.303 (1993). Although a July 1976 tuberculin tine test showed positive, a second test and a chest x-ray in August 1976 revealed negative results. The veteran has never received a diagnosis of pulmonary tuberculosis. Both the November 1990 and the May 1992 VA disability evaluation examinations, while noting a history of a positive tuberculin skin test, stated that a follow-up was negative for any abnormality and that there had not been a diagnosis or treatment for pulmonary tuberculosis. Similarly, although the veteran described one episode of loss of consciousness and "seizure" after venipuncture with treatment with intravenous glucose, this was an isolated incident, and she has had no problems since that time. She has not received a diagnosis of any disability manifested by hypoglycemia and currently does not have any problem related to hypoglycemia. Where a claimed disability is not shown in service and is not currently demonstrated, the claim is not well grounded. See Rabideau at 143. Accordingly, the claim must be dismissed. ORDER The claim for service connection for a stress reaction of the legs is dismissed. The claim for service connection for degenerative arthritis of the cervical and lumbar spine is dismissed. The claim for service connection for hypoglycemia is dismissed. The claim for service connection for a positive tuberculin test is dismissed. CHARLES E. HOGEBOOM Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), 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 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.