BVA9503936 DOCKET NO. 92-18 909 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to a compensable rating for disability of the right lower extremity, evaluated as the residuals of morphea of the right shin (previously evaluated as shin split injury with residual atrophy of the skin). ATTORNEY FOR THE BOARD Christine E. Puffer, Associate Counsel INTRODUCTION The veteran had active service from January 1972 to January 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 1992 rating decision of the Department of Veterans Affairs (VA) St. Petersburg, Florida, Regional Office (RO) which denied entitlement to the benefits sought on appeal. The appeal was remanded by Board decision of October 1993 for further development. As that action has been completed, the case is now ready for appellate review. CONTENTIONS OF APPELLANT ON APPEAL The appellant contends that he experiences pain in his right shin area when his right leg is bearing weight. He alleges that it impedes his ability to perform many activities of daily living such as extended walking, running, and other activities which involve weight-bearing. The appellant reports that he does not have full use of his right leg as it is unable to fully support his body weight without pain, limiting his physical activities. 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 preponderance of the evidence is against granting a compensable evaluation for disability of the right lower extremity, evaluated as the residuals of morphea of the right shin (previously evaluated as shin split injury with residual atrophy of the skin). FINDINGS OF FACT 1. All evidence necessary for an equitable adjudication of the instant claim has been obtained by the RO. 2. The veteran's service-connected right lower extremity disability is manifested by subjective complaints of discomfort, with no objective abnormal findings. CONCLUSION OF LAW The criteria for a compensable rating for disability of the right lower extremity, evaluated as the residuals of morphea of the right shin (previously evaluated as shin split injury with residual atrophy of the skin) have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. § 4.118, Diagnostic Codes 7899-7806 (1994). REASONS AND BASES FOR FINDINGS AND CONCLUSION As a preliminary matter, the Board finds that the veteran's claim 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 Board finds that he has presented a claim which is not implausible when his contentions and the evidence of record are viewed in the light most favorable to the claim. The Board is also satisfied that all relevant facts have been properly and sufficiently developed. I. Background The veteran was granted service connection for a shin splint injury with residual atrophy of the skin, apparently secondary to steroid injections with chronic weight bearing pain, at a noncompensable evaluation by rating action of May 1992. He contends that his service-connected right lower extremity condition is more severely disabling than his current evaluation reflects, and is seeking a compensable rating. Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155. Separate diagnostic codes identify the various disabilities. The percentage ratings are intended to represent the average impairment in earning capacity resulting from disability as a result of or incidental to military service. It is essential, in evaluating a disability, that it be viewed in relation to its history. 38 C.F.R. § 4.1. The veteran's service medical records include a March 1991 health record entry documenting the veteran's complaint of developing bilateral anterior shin pain when running. The assessment was of shin splints. At an examination in June 1991, he reported that his right anterior tibial pain was worse than his left, and that the symptoms had begun about a month and a half earlier, after running. The examiner noted point tenderness at the right mid- medial tibia with questionable swelling in the anterior compartment. Pain was reproduced with resisted dorsal flexion. The assessment was of the anterior tibial pain. Radiological examination of the veteran's right tibia and fibula that month revealed no bony abnormality or stress fracture. An August 1991 entry noted that the right tibial area was better after a cortisone injection. The veteran was given a physical profile in August 1991 for four months. The veteran underwent his retirement medical examination in October 1991. The examiner noted that the veteran had anterior tibial shaft pain, with a hypopigmented and hyperesthetic area which would need further treatment and evaluation after service. Later that month, the veteran underwent electromyography (EMG). He complained of constricting bands of pain periodically at different levels of his right leg. At that time, he was receiving treatment for a dermatologic lesion in his right leg. In reviewing the study's findings, the examiner concluded that there was no EMG evidence of neuropathy or radiculopathy in the right lower limb. In November 1991 the veteran was examined at the Orthopedic Clinic, he described his pain to be migratory, presenting below the knee and occasionally about the ankle. Physical therapy, anti-inflammatory medication and steroid injections were observed to have provided no significant benefit. On examination, some cutaneous changes of atrophy on the anterior aspect of his shin were noted. A full range of motion of his right knee and ankle was observed, with no instability. Full motor strength and normal alignment of the right leg were noted. The leg was slightly painful to palpation just above the medial malleolus of the ankle. The examiner opined that the veteran's pain was most consistent with a chronic tendonitis. Neurological and dermatological evaluations were suggested. The examiner noted that the medical group had "largely exhausted the diagnostic possibilities thus far." The veteran was seen by John L. Proffitt, M.D., on a dermatological referral in November 1991. He observed the veteran to have a small hypopigmented area on his right shin that felt slightly atrophic, or depressed. The area was nontender, but the veteran had been experiencing a deeper pain in the leg. He was assessed with possible morphea. A biopsy was performed that date and revealed that the biopsy pattern was consistent with morphea. Dr. Proffitt noted that there was an absence of inflammation, with no significant atypia or associated malignancy noted. The veteran underwent a bone scan in December 1991. No significant focal abnormality was observed in the right tibia, although some abnormality was observed in the left. On follow-up examination in January 1992, Dr. Proffitt noted that the veteran had no change despite medicinal therapy. He felt that the atrophic area was most likely secondary to corticosteroid injections, and was not true morphea. Dr. Proffitt reiterated this assessment in a January 1992 letter, stating he doubted the veteran had morphia. He opined that the area would correct itself, with no treatments. The veteran underwent a VA examination in March 1992. He reported itching on an atrophic area in his right mid-shin area. Some loss of hair covering about eight centimeters of skin, with atrophy and hypopigmentation was observed. The veteran reported receiving three steroid injections in that area. He complained of pain and tingling in three different bands of pain; below the knee, just above the ankle, and in the mid-shin area. The upper band area of pain had "just about disappeared." The pain was reported to be aggravated by any kind of weight bearing or use of the right leg. This had limited his walking ability. No particular tenderness of the leg was elicited, with the right calf measured as one-fourth of an inch smaller than the left. The veteran was able to squat and walk on his heels and toes. His gait was normal, and Patrick's test was negative. No deformities or instability of the knee was observed. Relevant diagnoses included atrophy of skin and loss of hair on the right lateral mid-shin area, and chronic weight-bearing pain mid-shin area, probably representing shin splint injury with a residual atrophy of the skin apparently secondary to steroid injection. Radiological examination of the right leg demonstrated a paucity of soft tissue anteriorly at the level of the midleg, although no underlying osseus abnormalities were identified. The tibia and fibula appeared intact. The Board issued a remand decision in October 1993. In addition to obtaining further medical records, an orthopedic examination was requested in order to obtain a definitive diagnosis of the veteran's right shin condition. At the time of a VA orthopedic examination in December 1993, the veteran complained of constant discomfort involving the anterior aspect of the right mid-tibia. He indicated that the sensation was of throbbing or tingling, rather than pain, and that the skin of the area occasionally became warmer than surrounding skin. Pain involving the proximal and distal right tibia in a band-like distribution was reported as well. The former pain was described as relatively infrequent, although the ankle discomfort was present daily. The symptoms were intensified with walking and weight bearing. He reported that the ankle caused him to fall once or twice in the shower, with his symptoms greatly limiting activities involving ambulating. The examiner reported that the veteran had no symptoms referable to his knee, hips, foot or ankle. The veteran was observed to have a normal gait, able to heel and toe walk normally, and was in no acute distress. A full range of motion in his knees, ankles and subtalar joints was elicited. No swelling, deformity or discoloration of the right leg was observed. The veteran complained of tenderness to palpation of a two-inch strip of the mid-anterior right tibia. Pedal pulses were palpable. Deep tendon reflexes at the knee and ankle were normal. The skin had normal pigmentation and hair growth, with no palpable temperature changes. The examiner concluded that there were no abnormal objective findings concerning the right leg and the skin overlying the right tibia. II. Analysis The veteran's right lower extremity disability has been evaluated as the residuals of morphea of the right shin (previously evaluated as shin split injury with residual atrophy of the skin), pursuant to Diagnostic Codes 7899-7806, for eczema. Under that code, a noncompensable evaluation is warranted with slight, if any, exfoliation, exudation or itching, if on a nonexposed surface or small area. A 10 percent evaluation is appropriate with exfoliation, exudation or itching, if involving an exposed surface or extensive area. With exudation or itching constant, extensive lesions, or marked disfigurement a 30 percent rating is warranted, and a 50 percent evaluation is warranted with ulceration, or extensive exfoliation or crusting, and systemic or nervous manifestation, or exceptionally repugnant eczema. Dr. Proffitt concluded that the veteran's dermatological condition of his right shin was most likely secondary to corticosteroid injections, and would resolve spontaneously, without treatment. This evaluation appears to have been accurate as on recent VA examination the veteran was observed to have no hair loss, abnormal pigmentation, deformity or temperature changes of the skin of his right lower extremity. No objective abnormal findings were evidenced whatsoever. Therefore, a compensable evaluation under the cited diagnostic code is not warranted. Although review of the veteran's service-connected right lower extremity disability is available under other diagnostic codes, such review is similarly unavailing. The veteran's condition was originally evaluated under Diagnostic Code 5299-5262, for impairment of the tibia and fibula. 38 C.F.R. § 4.71a. At the minimum, for a compensable evaluation under that section, the veteran would have to demonstrate malunion of the tibia and fibula with slight knee or ankle disability. Although the veteran has undergone EMG testing, a bone scan, radiological studies and numerous examinations, no objective abnormalities of his right lower extremity have been found. As there is no evidence of any impairment of the right tibia or fibula, a compensable evaluation under that code is inappropriate. The Board recognizes that the veteran has consistently reported experiencing pain in his right lower extremity. It is noted that he originally reported it in both lower extremities, subsequently indicating that it was in one area on his right shin, then reporting it as presenting in three "bands" around his right lower extremity, and most recently as in two "bands" and on the anterior aspect of the right tibia. He has consistently reported that his symptoms worsen with weight bearing, and has indicated that his loss of function of his right lower extremity has been due to pain. The rating schedule is intended to compensate for functional loss of the musculoskeletal system due to pain; however, this must be supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. The rating schedule is also intended to recognize painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Similarly, painful motion is to be recognized where there is evidence of associated joint or periarticular pathology, as productive of disability. 38 C.F.R. § 4.59. The veteran has never been observed by any examiner to have any deviations in his gait or in his ability to ambulate, and he has been able to squat and perform heel and toe walking without difficulty. Most importantly, the record is completely devoid of any evidence of abnormal pathology of the right lower extremity despite extensive testing and evaluation. As such, a compensable evaluation is not warranted based on functional loss or painful motion as neither is supported by any clinical evidence of joint, musculoskeletal or periarticular pathology. In reaching its decision, the Board has considered the complete history of the disability in question as well as the current clinical manifestations and the effect the disability may have on the earning capacity of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. The nature of the original injury has been reviewed and the functional impairment which can be attributed to pain or weakness has been taken into account. 38 C.F.R. § 4.40. The manifestations of the veteran's right lower extremity disability are not so exceptional or unusual so as to warrant a compensable evaluation on an extra-schedular basis. The veteran has not indicated that his disability has caused any interference with employment, and it has not necessitated any period of hospitalization. 38 C.F.R. § 3.321(b)(1). ORDER A compensable rating for disability of the right lower extremity, evaluated as the residuals of morphea of the right shin (previously evaluated as shin split injury with residual atrophy of the skin), is denied. 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.