Citation Nr: 0001645 Decision Date: 01/20/00 Archive Date: 01/28/00 DOCKET NO. 98-08 860 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for Reiter's syndrome. 2. Entitlement to service connection for a left ankle disorder. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD James J. Dunphy, Counsel INTRODUCTION The veteran served on active duty from August 1968 to August 1970. The case was previously before the Board of Veterans' Appeals (Board) in March 1999, at which time it was remanded to the Department of Veterans Affairs (VA) Regional Office (RO) for further development. The case is once more properly before the Board for action. The Board noted in the March 1999 decision that the RO had denied service connection for residuals of exposure to Agent Orange, and subsequent to a timely Notice of Disagreement (NOD), the RO issued a statement of the case (SOC). No appeal had been forthcoming from the SOC at the time that the case was referred to the Board for action. While the case was at the RO for further development, the veteran did not submit a substantive appeal on the issue of entitlement to service connection for residuals of Agent Orange exposure. Hence, this issue is not before the Board for review. FINDINGS OF FACT 1. The veteran has not presented medical evidence demonstrating a nexus between calcaneal bursitis in service and a post service left ankle disorder. 2. Current Reiter's syndrome is not the result of venereal disease in service. CONCLUSIONS OF LAW 1. The veteran has not submitted a well grounded claim with regard to the issue of entitlement to service connection for a left ankle disorder. 38 U.S.C.A. §§ 1110, 5107 (West 1991); 38 C.F.R. § 3.303 (1999). 2. Reiter's syndrome was not incurred in or aggravated by service. 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. § 3.303 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Factual Background A review of the service medical records indicates that when the veteran was seen in December 1968, he reported pain in the left ankle, of three weeks duration. On examination, there was diffuse swelling and tenderness posterior to the malleolus and superior to the calcaneus. An X-ray report was negative for abnormalities. The impression was calcaneal bursitis. No further treatment was required. He was improved when seen 10 days later, but there was still some swelling. He was treated in July 1969 for gonorrhea. Treatment for a ureteral discharge was required in November 1969. When the veteran was examined for separation from service in July 1970, he reported unspecified bone or joint deformities. No pertinent abnormalities were reported or found. The veteran was hospitalized in a VA facility in September 1994, so that he could qualify for special prosthetic shoes required for his deforming foot arthropathy. The diagnoses included Reiter's syndrome and painful feet. The veteran was hospitalized in a VA facility in December 1995 for treatment of abdominal complaints. No complaints were elicited with regard to the lower extremities, and no pertinent findings were made. He again required hospitalization in a VA facility in November 1995, December 1995 and June 1996 for treatment of abdominal complaints, and in December 1997 for pneumonia. Of record are reports of outpatient treatment afforded the veteran by the VA. In an August 1993 note, the veteran reported bilateral ankle pain, responding to non steroid anti inflammatory drugs. He was again seen in May 1994, at which time he reported chronic ankle pain. The pain was worse towards the end of the day and with motion. The veteran retained full range of motion of the ankles, without swelling. The impression was chronic arthralgia, due to questionable osteoarthritis versus rheumatologic diagnosis. He gave a history, when he was seen in July 1994, of "rheumatism" since age 20. (The Board notes that the veteran turned 20 approximately one month into his period of active duty.) The veteran reported that the problem started with foot swelling and chronic back problem. He was treated with medication, and showed some improvement. He now reported bilateral elbow pain without swelling. There were chronic deformities of the feet, without knee pain. After examination, the assessment was deforming arthritis. The veteran reported constant dull pain in both feet when he was seen in August 1995. There was also constant dull pain in the lower back, worsened by walking. The assessment included Reiter's syndrome, by history. Of record is a report of treatment by Kenneth Davis, M.D., in August 1985. At that time, the veteran noted the symptoms were mainly confined to the feet and ankles. No new pathology was reported. The assessment was rheumatoid arthritis. In a reply to a May 1996 VA letter, Dr. Davis indicated that he had not seen the veteran for over three years. Stuart A. Leder, M.D., submitted a report on his treatment of the veteran in April 1997. The veteran carried a diagnosis of generalized sensory motor polyneuropathy. The symptoms included burning paresthesias of both feet. Potential etiologies include exposure to Agent Orange in the Vietnam War, which was known to cause such peripheral neuropathies. The Board notes that a review of the veteran's service indicates that he served in Vietnam. Another contributing etiology was Reiter's syndrome as well as probable rheumatoid arthritis, both of which combine to form a mixed connective tissue disease. The sensory motor peripheral neuropathy caused functional impairment. The arthritic condition caused obvious joint deformities of the hands and feet, clearly defined on examination, and resulting in arthralgias which impair his ability to work as a mechanic. At his formal hearing before a traveling member of the Board in November 1998, the veteran testified that the Reiter's syndrome was the result of venereal disease in service (Transcript, hereinafter T-4,5). He made reference to the treatment in service for the calcaneal bursitis. (T- 13). He reported he did not seek any additional treatment, but has required treatment subsequent to discharge. (T-14, 15). Currently, the disability manifested by pain, relieved by sitting. (T-16). The veteran also submitted a letter from Scott D. DeWitz, M.D., dated in November 1998. Dr. DeWitz noted that studies seemed to confirm that Reiter's syndrome is often related to venereal disease as a delayed cause and effect. He concluded that it was more than likely that the veteran's Reiter's syndrome was related to the venereal disease contracted during his period of active duty. Subsequent to Board remand, the veteran was examined for compensation purposes by the VA in August 1999. He reported the treatment in service for gonorrhea and urethritis. He stated that he did not have any skin or joint conditions at that time. There was progressive joint pain, but the veteran could not specify when the pain started. Also reported were worsening in both feet, swelling in the right hand and severe problems with his ankles. On examination, there was normal alignment of the cervical spine, with minimal tenderness and adequate range of motion. Minimal tenderness was present in the shoulders, with flexion possible to 160 degrees. He retained adequate elbow flexion, without deformities or swelling. He retained a good hand grip, without swelling or deformity. Both hips showed adequate range of motion. There was decreased range of motion of the ankles, with very marked limitation of dorsiflexion on the left. Severe tenderness was present in the metatarsal area, with complete destruction of the normal anatomy of the metatarsal area bilaterally. There was apparent erosion of the metatarsal bones resulting in mild shortening of the metatarsal area. He was unable to walk on his heels and toes. Lichenification was present in the medial aspect of both ankles, with hyperpigmentation over the dorsal aspect of the feet. There was no onychomycosis or destruction of the toenails. The impression was erosive inflammatory arthropathy affecting mostly the peripheral joints and the lumbar spine. The examiner concluded that the veteran most likely had Reiter's syndrome or psoriatic arthritis. However, in view of the fact that there were no marked psoriatic patches, there was a higher possibility of Reiter's syndrome. The veteran did not present the full clinical dermatological manifestations of Reiter's syndrome at the time of examination. He never had any rash consistent with the condition that is most common in the plantar areas, and there were no toenail changes. There was no ocular involvement with the Reiter's syndrome, and no evidence of uveitis. It was difficult to determine exactly the onset of the Reiter's syndrome. There was no symptomatology after the first two episodes of gonorrhea and urethritis in service. He did not present symptomatology for more than 20 years. Based on this history, the examiner concluded that it was less likely that Reiter's syndrome was related to the episodes of gonorrhea in service. The examiner noted that the claims file was reviewed prior to rendering his opinion. Also obtained were more recent reports of outpatient treatment. In a September 1998 note, it was indicated that the veteran had an 18 to 19 year history of Reiter's syndrome. This history was noted in additional reports of outpatient treatment. Analysis The veteran is contending that service connection is warranted for joint disorders. The claim has been developed as two issues - the first being service connection for a left ankle disorder and the second being service connection for Reiter's syndrome, which could include symptomatology in the left ankle. Turning first to the issue of service connection for a left ankle disorder, independent of Reiter's syndrome, the Board notes that service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110 (West 1991). 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) (1999). However, the threshold question that must be resolved is whether the veteran's claim of entitlement to service connection is well grounded; that is, whether it is plausible, meritorious on its own, or otherwise capable of substantiation. See Chelte v. Brown, 10 Vet. App. 268, 270 (1997) (citing 38 U.S.C.A. § 5107(a) and Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990)). If the claim is not well- grounded, the appeal fails and there is no further duty to assist in developing the facts pertinent to the claim. See Anderson v. Brown, 9 Vet. App. 542, 546 (1996); see also Epps v. Gober, 126 F.3d 1464, 1468-69 (Fed. Cir. 1997). In order for a claim to be well grounded, there must be competent evidence of a current disability (a medical diagnosis); evidence of incurrence or aggravation of a disease or injury in service (lay or medical evidence); and evidence of a nexus between the inservice disease or injury and the current disability (medical evidence). See Caluza v. Brown, 7 Vet. App. 498, 506 (1995). Where the determinant issue involves a question of a medical diagnosis or causation, competent medical evidence is necessary to establish a well grounded claim. See Epps, supra (citing Caluza, supra, and Grottveit v. Brown, 5 Vet. App. 91, 93 (1993)). Lay assertion of medical causation or a medical diagnosis cannot constitute evidence to render a claim well grounded. Grottveit, supra; Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). The Board notes that the veteran was treated for calcaneal bursitis in service, and there are reports of treatment for left lower extremity disorders subsequent to service. However, for the veteran's claim to be well grounded, he must present medical evidence establishing a nexus between the post service disability and the incidents of service. The evidence does not contain such nexus evidence, and hence his claim is not plausible. A review of the findings on post service treatment and hospitalizations reveal no conclusions in support of the contention that a post service organic left ankle disorder had its origin in the symptomatology in service. While when the veteran was treated in June 1994, he gave a history of rheumatism beginning in service and resulting in foot swelling, this history was not confirmed by either the reports of treatment in service or by the treating physician. Such unenhanced history cannot render a claim well grounded. LeShore v. Brown, 8 Vet. App. 206 (1995) Instead, the Board is left with the veteran's contentions and testimony, without support of medical evidence. As the veteran is not a medical professional, his opinions on medical causation, standing alone, cannot render a claim well grounded. See Grottveit and Espiritu In the absence of medical nexus evidence, the veteran's claim for service connection for a left ankle disorder arising out of the incidents of service is not well grounded. Savage v. Gober, 10 Vet. App 489 (1997). Therefore, his claim to this extent must be denied. The veteran has further contended that service connection is warranted for Reiter's syndrome, and argues that this disability is the result of venereal disease in service. Initially, the Board finds that the veteran's claim for service connection for this disability is well grounded within the meaning of 38 U.S.C.A. § 5107(a). See Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). That is, the veteran has presented evidence of a current disability; he has also indicated that such disability had its origins during service; and he presented medical nexus evidence from Dr. DeWitz that tends to link his current Reiter's syndrome to the venereal disease that he had during service. Caluza, 7 Vet. App. at 506. In determining that the veteran's claim is well-grounded, the credibility of evidence has been presumed and the probative value of the evidence has not been weighed. However, once the claim is found to be well-grounded, the presumption that it is credible and entitled to full weight no longer applies. In the adjudication that follows, the Board must determine, as a question of fact, both the weight and credibility of the evidence. Equal weight is not accorded to each piece of material contained in a record; every item of evidence does not have the same probative value. The Board must account for the evidence which it finds to be persuasive or unpersuasive, analyze the credibility and probative value of all material evidence submitted by and on behalf of a claimant, and provide the reasons for its rejection of any such evidence. See Struck v. Brown, 9 Vet. App. 145, 152 (1996); Caluza v. Brown, 7 Vet. App. 498, 506 (1995); Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994); Abernathy v. Principi, 3 Vet. App. 461, 465 (1992); Simon v. Derwinski, 2 Vet. App. 621, 622 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164, 169 (1991). VA has a duty to assist the veteran in the development of facts pertinent to a well-grounded claim. 38 U.S.C.A. § 5107(a); see also Littke v. Derwinski, 1 Vet. App. 90 (1990). The Board is satisfied that all relevant facts have been properly and sufficiently developed. A review of the veteran's service medical records indicates that he was treated in service on a number of occasions for venereal disease. Moreover, the veteran has presented evidence showing the current presence of Reiter's syndrome. In particular, the Board has considered the report of VA compensation examination in August 1999, subsequent to the Board remand. At that time, the examiner concluded that the veteran's disability was most likely Reiter's syndrome. This is consistent with the reports of private and VA medical treatment. For service connection to be warranted, however, the veteran must demonstrate that the Reiter's syndrome resulted from the venereal disease in service. As this question is medical in nature, the Board must weigh the conclusions reached by medical professionals. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). In support of the veteran's contention is a statement by Dr. DeWitz. He noted that Reiter's syndrome is often related to venereal disease as a delayed cause and effect, and he found that it was more than likely that the veteran's Reiter's syndrome was related to the venereal disease the veteran contracted during service. The statement by Dr. Leder indicated that the veteran had generalized sensory motor polyneuropathy, which could have been the result of either Reiter's syndrome or Agent Orange exposure the veteran underwent in Vietnam. As noted, the issue of service connection for residuals of Agent Orange exposure is not before the Board for review. In opposition to the veteran's contention are the conclusions reached by the examining physician during the August 1999 VA compensation examination. That examiner concluded that while the veteran demonstrated Reiter's syndrome, it was difficult to determine exactly the onset of the disorder. However, given that the veteran did not manifest any symptomatology of Reiter's syndrome for more than 20 years after the onset of the venereal disease in service, it was less likely [than not] that the Reiter's syndrome was related to the episodes of gonorrhea in service. In weighing these two opinions, the Board must afford substantially greater probative weight to the conclusions reached on the VA compensation examination. In reaching his conclusion, Dr. DeWitz apparently considered studies, but did not support his conclusion by specific references to the veteran's case. On the other hand, the examining VA physician reviewed the veteran's claims file and provided specific rationale when he concluded that the fact that no symptomatology was present for more than 20 years after the onset of the venereal disease in service rendered it less likely that the Reiter's syndrome was related to the in service disorder. In view of the detailed findings reported on examination, and given that the examiner made reference to specific incidents in the veteran's case instead of reference to general studies, the Board finds that the 1999 VA examiner's opinion outweighs the opinion of Dr. DeWitz. The United States Court of Appeals for Veterans Claims (Court) has held that it is the Board's duty to determine the credibility and weight of evidence. Wood v. Derwinski, 1 Vet. App. 190 (1991). While the Board may not ignore the opinion of a physician, it is certainly free to discount the credibility of that physician's statement. Sanden v. Derwinski, 2 Vet. App. 97 (1992). Greater weight may be placed on one physician's opinion than another's depending on factors such as reasoning employed by the physicians and whether or not and the extent to which they reviewed prior clinical records and other evidence, Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994), and an opinion may be discounted if it materially relies on a layperson's unsupported history as the premise for the opinion. Wood v. Derwinski, 1 Vet. App. 190, 191-192 (1991). In his December 1999 written arguments, the veteran's representative claimed that the evidence in support of the claim was equal to that against the claim, and that being the case, the appeal should be allowed. When all the evidence is assembled, the Secretary 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 a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). For the reasons outlined above, the Board has found that the VA examiner's opinion in 1999 is of higher probative value and outweighs the opinion in favor of the claim. As such, the preponderance of the evidence is against the veteran's claim. Accordingly, the veteran's claim in this regard must be denied. ORDER Service connection for a left ankle disorder is denied. Service connection for Reiter's syndrome is denied. M. Sabulsky Member, Board of Veterans' Appeals