Citation Nr: 0007929 Decision Date: 03/23/00 Archive Date: 03/28/00 DOCKET NO. 93-16 916 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Milwaukee, Wisconsin THE ISSUES Entitlement to service connection for a low back disability, as proximately due to or the result of the veteran's service- connected disabilities. Entitlement to a bilateral foot disability, as proximately due to or the result of the veteran's service-connected disabilities. REPRESENTATION Appellant represented by: Mark R. Lippman, Attorney WITNESS AT HEARINGS ON APPEAL The veteran ATTORNEY FOR THE BOARD Neil Reiter, Counsel INTRODUCTION The veteran served on active duty from May 1966 to April 1968. He has been granted service connection for residuals of a right knee injury, residuals of a fracture of the right great toe, and tinea pedis. Beginning in 1991, the veteran submitted claims for a low back disability, to include low back strain and lumbar disc disease, a bilateral foot condition, to include circulatory problems in the feet and pes planus, a disability of the right shoulder, and additional disability of the right foot and leg, variously diagnosed as peripheral vascular disease or reflex sympathetic dystrophy. The veteran also requested increased ratings for his service-connected disabilities, and a total rating by reason of individual unemployability. In a rating in May 1991, the regional office increased the veteran's rating for residuals of an injury to the right knee from 10 percent to 20 percent, effective from February 8, 1991, and increased the rating for residuals of a fracture of the right great toe from 0 percent to 10 percent, effective from February 28, 1991. The regional office denied the veteran's claims for service connection for the claimed disabilities, and for a total rating based on individual unemployability. The veteran appealed the denied claims, and testified at a hearing before the Board sitting at Milwaukee, Wisconsin in July 1993. In July 1995, the Board remanded the case for additional development. After more information was received, the regional office again denied the veteran's claims. The veteran testified at a hearing before the Board in October 1997. In July 1998, the Board determined that the veteran's claim for service connection for a bilateral foot disability was not well grounded. The Board also determined that a low back disability, claimed additional disability of the right foot and leg, variously diagnosed as peripheral vascular disease or reflex sympathetic dystrophy, and a disability of the right shoulder were not incurred in or aggravated by active service or proximately due to or the result of a service-connected disability. The Board also denied a total rating based on individual unemployability. Thereafter, the veteran appealed to the U.S. Court of Appeals for Veterans Claims (the Court). Briefs for the appellant and for the Department of Veterans Affairs (VA) were filed. In September, 1999, the Court determined that since the veteran had not addressed the claims of entitlement to service connection for additional disability of the right foot and leg, variously called peripheral vascular disease or reflex sympathetic dystrophy, and the claim for a total rating by reason of individual unemployability in any of his briefs before the Court, such claims on appeal were deemed abandoned. Further, the Court upheld the Board's determination that the appellant was not entitled to service connection for a right shoulder disability. In reviewing the veteran's claim for service connection for a low back disability, the Court noted that the brief and reply brief, in essence, had abandoned any argument that the back condition was incurred in or aggravated directly by service. The Court further indicated that, even assuming that he had not abandoned such argument, because of inconsistent histories provided by the appellant, and because a statement introduced by the veteran's physician was conclusory and based on a history unsupported by evidence, there was a plausible basis in the record for the Board finding that there was no direct causation between any inservice injury or disease and the current back disability. The Court, however, found that the Board had not addressed with sufficient reasons and bases the veteran's claim for secondary service connection for a back disability. Therefore, the Court remanded the veteran's claim for secondary service connection for a back disability to the Board. Finally, the Court determined that the veteran's claim for service connection for a bilateral foot disability was well grounded, as a statement by one of the veteran's physicians diagnosed circulatory problems and fallen arches, and indicated that there was some causal connection linking the veteran's service-connected disabilities to a chronic low back disability, which, in turn, caused the fallen arches and a circulatory problem in the feet. The Court concluded that the appellant's claim for secondary service connection for a disability of both feet was therefore well grounded, and remanded this claim for consideration by the Board on its merits. The case has now been returned to the Board for further appellate consideration of the two remaining claims. FINDINGS OF FACT 1. The regional office has obtained all relevant evidence necessary for an equitable disposition of the veteran's claims. 2. A chronic low back disability, including low back strain and lumbar disc disease, is not etiologically related to, caused by, or the result of the veteran's service-connected disabilities. 3. Any chronic disability of both feet, claimed as circulatory problems and fallen arches, is not etiologically related to, caused by, or the result of the veteran's service-connected disabilities. CONCLUSIONS OF LAW 1. A chronic low back disability, including low back strain and lumbar disc disease, is not proximately due to or the result of any service-connected disease or injury. 38 U.S.C.A. § 5107 (West 1991); 38 C.F.R. § 3.310 (1999). 2. A chronic disability of both feet, including circulatory problems and fallen arches, is not proximately due to or the result of the veteran's service-connected disabilities. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Court has determined that the veteran's present claims for secondary service connection are "well grounded" within the meaning of 38 U.S.C.A. § 5107. On appeal, the veteran has maintained that he has a chronic back condition and bilateral foot condition which are the result of his service-connected disabilities. Specifically, the veteran maintains that there is medical evidence establishing that the chronic low back condition is the result of aberrant functioning of the lower extremities caused by the disabilities of the right knee and right foot. He maintains that the disabilities of the right foot and right knee have caused undue stress on the biomechanical integrity of the lower back, causing a chronic back condition and degenerative changes. Further, he maintains, that the evidence shows that circulatory problems and fallen arches can be directly traced to the veteran's chronic back disability. He contends that his physician has indicated the nerve problems in the lower back have contributed to, and caused, circulatory problems and fallen arches in both feet. I. Background Service medical records contain a report that the veteran sustained a fracture of the right patella in February 1968, and that he was placed on limited duty after receiving treatment for this disability. On examination for discharge from service in April 1968, the veteran reported that he was "run over" by a bus, injuring his right leg, necessitating a patellectomy. He reported that he was able to walk with crutches. He checked the box "no" when asked whether he had, or had had, recurrent back pain. On physical examination, it was indicated that the right foot was still swollen and painful. Range of motion of the right knee was from 130 degrees to 5 degrees with slight pain. The physical examination was otherwise normal. It was recommended that he continue with physical therapy. On a VA examination in July 1968, the veteran reported that he had been "run over" by a bus, sustaining a fracture of the right patella and a fracture of the right big toe. He indicated that he had been hospitalized until separation. His complaints included cracking in the knee, swelling in the right foot, and lameness in the right knee. On physical examination he walked without a limp. He could stand on his toes, but complained of pain in the right foot. He could walk on his heels, and he could squat fairly well. There was no effusion, abnormal mobility or instability, swelling, or limitation of motion of the right knee. There was some crepitus. The right thigh was 1 inch less in circumference than the left thigh, and the veteran indicated that he was doing quadriceps exercises to strengthen these muscles. On further physical examination, there was no edema of the right leg, and there was no swelling of the right foot. There was no obvious deformity of the right foot. There was no limitation of motion of the right ankle or right foot. The veteran indicated that the swelling in the right foot was becoming less than previously. X-rays of the right foot showed osteoarthritic changes in the interphalangeal joint of the great toe. The x-ray of the right knee was read as normal. Otherwise, the remaining bones and joints of the foot were normal. The diagnoses included history of injury and surgery to the right knee, and history of fracture of the great toe, with traumatic arthritis of the interphalangeal joint. In a rating in August 1968, the veteran was granted service connection for residuals of an injury to the right knee, evaluated as 10 percent disabling, and for residuals of a fracture of the right great toe with arthritic changes of the interphalangeal joint, evaluated as 10 percent disabling. A report from Sacred Heart Hospital dated in January 1973 indicates that the veteran requested treatment for pain, lower temperature, and discoloration in the toes of both feet, right greater than left. He reported that he had been playing hockey in the evening in very cold temperatures, about 10 degrees below zero, wearing only a plastic bag over his feet, with no stockings. When he arrived home, he stated that he tried to warm the toes with hot soaks, but continued to feel the residuals of the cold in the toes of both feet. On physical examination, the right great toe and second through fourth toes appeared bluish, without blistering and with very little swelling. On the left foot, the second through fourth toes appeared affected. He was treated with warm soaks. The diagnosis was frostbite of the first through the fourth right toes and second through fourth left toes. On a VA examination in July 1973, the veteran complained of soreness and numbness of the right leg and right foot after standing for about four hours. He stated that he developed a limp if he did not rest for a period of time. He indicated that he had morning stiffness of the right foot, which disappeared after 10 minutes, and a slight swelling of the right foot on occasion. He stated that he had sustained frostbite of the toes of the right foot the previous winter, noting that he had lost several toenails. He complained of stiffness and weakness of the right knee with prolonged activity. His history of an injury to the knee and right foot in service was noted. On physical examination the legs were symmetrical. There was some crepitation in the right knee. The right foot and toes appeared normal, and the measurements of the ankles, knees, and arches were equal in both legs. Motion of the knees, ankles, and feet were full, free, and unrestricted. There was no evidence of any muscle atrophy or weakness. The diagnosis was status post arthrotomy, right knee, recovered, and status post fracture of the right great toe, no residuals demonstrated. In a rating in August 1973, the 10 percent evaluation for disability of the right knee was continued. The rating for residuals of a fracture of the right great toe was reduced to 0 percent, effective from November 1, 1973. In early 1991, the veteran requested service connection for disability of the feet, noting that he had bad circulation in the right foot and leg. He subsequently requested service connection for a chronic back condition. A statement was received from Timothy P. Wolter, D.C., in March 1991, indicating that he had been treating the veteran since June 1988 for low back, leg, and foot problems. Dr. Wolter expressed the opinion that one of the reasons the veteran's low back was chronic was because of his foot and leg. Dr. Wolter indicated that the veteran tended to favor the foot, thereby changing his gait, which, in turn, put stress on the low back. A statement was received from James M. Abens, D.C., in April 1991 indicating that he had recently examined and taken a case history from the veteran. Dr. Abens expressed the opinion that the veteran had 15 percent impairment as the result of a low back condition and was 35 percent disabled. He indicated that 5 percent of the 15 percent of the back could be ascribed to a traumatic accident that occurred while the veteran was in the military, 5 percent to a work-related injury that occurred the previous November, and that 5 percent could be ascribed to other work-related injuries. Dr. Abens said that the remaining 20 percent impairment could be shown to be due to 5 percent for each of four different areas, the left shoulder, right knee, and each foot. In a statement in April 1991, the veteran reported that the bus in service had run over the entire right side of his body, including his right foot, right knee, right hip, and right shoulder. On a VA examination in March 1991, the veteran complained about fallen arches in the feet, lower back pain, pain in the feet, numbness in the right foot and the right leg, and bad circulation in the lower extremities. He noted increasing problems with the right knee and back, indicating that he had been using a cane intermittently for the last 10 years. He stated that he did not use a brace or use any medication for the knee. He complained of some instability in the knee, but no swelling, and he stated that he had problems standing, walking or sitting. On physical examination, the knee was tender to palpation, and range of motion was from 0 to 110 degrees, with pain at 110 degrees. There was no evidence of effusion, but there was evidence of some instability. Examination of the right great toe showed some tenderness to palpation over the interphalangeal joint. The range of motion of this joint was from 0 degrees to 30 degrees, with complaints of pain. X-rays of the right knee showed a possible old fracture deformity of the proximal right fibula. X-rays of the right foot showed a metallic density. The diagnoses included history of right knee injury, postoperatively, with residuals, and history of fracture of the right great toe, with residuals. In a rating in May 1991, the evaluation for the disability of the right knee was increased to 20 percent, effective from February 28, 1991, and the evaluation for disability of the right great toe with arthritis was raised to 10 percent, effective from February 28, 1991. A statement was received from R. L. Buechel, M.D., indicating a recent examination of the veteran for complaints of back pain. The veteran indicated that he had had back pain since an incident in 1968 and a recent job injury in November 1990. His present symptoms included shooting pain in the lower back with radiating pain and numbness down the legs. Physical examination showed that the veteran was able to walk without a limp. It was noted that there was a slightly less high arch on the left than the right. There was some limitation of motion of the lumbar spine. There was no motor or sensory deficit in the upper or lower extremities. X-rays and a CT scan of the lumbar spine in 1991 had shown narrowing of the lower lumbar disc, with a cut-off of the nerve root, and some bulging of the lower lumbar discs. The diagnosis was early spondylolysis of the lower lumbar spine, with evidence of possible disc herniation of the lower lumbar discs. A letter from Dr. Abens in December 1991 indicated that he had treated the veteran since March 1991 for various orthopedic problems. Dr. Abens stated that it was a well- known medical fact that traumatic injury to bony and soft tissues of the human body will result in degenerative changes in that immediate area as the years progress, and that when such injuries occur in the lower extremities, it is very common for the patient to suffer degenerative changes in the spine that are a direct result of the previous extremity trauma. He stated that if there were any aberrant function or motion in any of the joints of the lower extremity from one side, compared to the other, than such abnormalities will show up in extra wear and tear on the spinal column, particularly in the lower area. Dr. Abens stated that the X-rays of the veteran's lumbar spine showed degenerative changes in the lower lumbar area. He indicated that it was widely accepted by biomechanical spinal experts that most degenerative changes in the lower back are the result of years of abnormal function or motion or inordinately high stress in that area. He stated that, if one were to thoroughly examine the veteran's case, such persons would determine that the functional problems in the veteran's lower back could be directly related to the traumatic accident that occurred in service. He indicated that it was very common for there to be a large hiatus between the initial injury and functional problems that occur later. Dr. Abens stated that the veteran's right foot and right knee had been functionally aberrant since the service accident. He indicated that these two injuries, alone, had resulted in a great deal of physical disability. He stated that the "bogus right foot and knee" had caused undue stress on the biomechanical integrity of the lower back, which had resulted in degenerative changes. He stated that he had volumes "of hard core scientific research that has been published in referenced index journals all of which totally back up the opinions I have put forth in this letter." He also stated that this explanation could apply to the veteran's poor lower extremity circulation and fallen arches in his feet. Dr. Abens stated that the service accident caused injuries to the right foot and right knee, "as well as other structures in his body." These right lower extremity injuries resulted in dysfunction in the lower back. "This resulted in nerve interference relative to the nerves" that went into the veteran's legs. This led to abnormal function at the nerve endings, and this was the most probable explanation of why the veteran had developed bilateral circulatory problems and fallen arches in both feet. A statement was received from the veteran's wife in July 1993 indicating that she had been married to the veteran for 24 years. She stated that the veteran's injuries in service included injuries to the back, leg, foot, and shoulder. She stated that the veteran used a cane at times, and that he had bad back, leg, and foot pain at times. She also suggested that these problems caused circulatory problems, numbness, and a cold feeling in the feet. At a hearing before the Board sitting at Milwaukee, Wisconsin, in July 1993, the veteran again mentioned that the accident in service caused the bus to ride over the entire right side of his body. He indicated that he had been hospitalized six months, and that he had injured his back in service. He mentioned an industrial accident in 1990. He believed his circulatory problems dated back and were tied to the 1973 incident of frozen feet. He sometimes had pain in the back that radiated down his foot. He had been told that he had fallen arches, and he had been fit with orthopedic shoes, with lifts, about eight years previously. He worked in the Post Office as a mail sorter. Pursuant to the Board's remand in July 1995, a search for further service medical records was unsuccessful. Dr. Abens submitted his clinical records relating to treatment of the veteran beginning in 1991. On a patient history, the veteran reported that he had been involved in an accident in service in which a bus ran over the entire right side of his body, and that he had had problems with his feet, legs, back, and shoulders since that accident. He also noted a back problem on the job in November 1990. Clinical records of the veteran's treatment at Midelfort Clinic for the period from 1987 through 1995 were also received. In July 1987, the veteran complained of an acute exacerbation of chronic back strain, and some leg problems. In June 1988, he indicated that he was having problems with his right leg and knee. He provided a history of being run over by a bus, injuring his right foot, right knee, right hip, and right shoulder. He stated that he originally had some disability of the knee and foot, but was then able to ambulate and be fairly active, without any particular problems. It was noted that at some point after service he played hockey and performed other physical activities. The veteran noted, however, that he had shooting pain in the right foot on occasion, and that he had problems with stability of the right knee. Physical examination showed good muscle tone in the right leg, with reasonably good strength. Pulses were good peripherally. There was some tenderness in the right knee. The diagnoses included chronic injury of the right leg. In August 1988, the veteran was referred for orthopedic consultation for problems of his right knee. The veteran indicated that he had had occasional difficulties in the right knee since the accident in service, with more frequent problems recently. Examination showed no effusion, but some minimal instability. Dorsalis pedis and posterior tibial pulses were palpable. X-rays of the knees showed some minimal spur formation of the patella. In December 1989, the veteran was examined prior to scheduling a vasectomy. He indicated that he had no particular problems other than those associated with his legs. Physical examination was essentially normal. In February 1990, the veteran complained of pain in his legs and feet, including fallen arches. A physical examination on November 1, 1990 failed to show any physical abnormalities. In late November 1990, the veteran reported that he had hurt his back on the job. He reported that he was lifting a tray of mail from the bottom of a wall unit when he felt something kind of pull in his lower back. He noted that subsequently he developed some tenderness, pain and a tightening feeling in his lower back, radiating into the right leg. The diagnostic impression was low back strain with radiculopathy. Subsequently, he continued to have problems with back pain, with some complaints of numbness radiating down the right leg. A CT scan in November 1990 showed some bulging discs in the lower lumbar spine. A CT scan in January 1991 showed some disc protrusion at L4-5. An X-ray of the lumbar spine in January 1991 showed some disc narrowing in the lower lumbar spine, degenerative in nature. A lumbar myelogram in January 1991 showed an extradural defect in the lower lumbar spine. A MRI of the lumbar spine in June 1992 showed mild disc bulging. A notation in the clinical notes in June 1992 indicated that the veteran had undergone myelography and CT scans indicating a mild disc herniation at L4. It was indicated further that the veteran had some spasm-like pain in the back and in the right calf with episodes of dysesthesia in a distribution which corresponded to the L5 nerve root. A notation in February 1994 indicates that the veteran did respond somewhat to physical therapy, but continued to have problems, including walking, at times, with a slight limp. In 1995, it was indicated that the veteran was seeking permanent disability from his job at the Post Office. A history taken in August 1995 noted that the veteran had been run over by a bus in service, with the bus running over his right foot, right knee, right hip, and right shoulder. The veteran stated that, as a residual of this, he had an ongoing difficulty with "reduced circulation" in the right knee and right upper and lower extremities. A second injury occurred in 1990 when he was working for the Post Office Department. Clinical reports were also received from Dr. Wolter. Statements were received from the veteran's wife and daughter attesting to the current nature of his physical problems. A statement from a co-worker dated in July 1995, noted that the veteran had been having trouble with his back for 13 years. Another co-worker indicated that he had begun working with the veteran in 1983, that at that time, the veteran had no limitation as far as physical performance on the job, and that the veteran spent many hours working overtime. This worker noted that the veteran began having problems with a back condition as the years passed. On a VA orthopedic examination in February 1996, the veteran again described the accident in service, stating a bus had rolled over the right side of his body. He indicated that he was on crutches for about one year after the injury in service, and then walked with a cane. The veteran's records relating to his back disability, including the records from the Midelfort Clinic were reviewed. Physical examination showed that he could not walk consistently on the right foot. The longitudinal arches were well maintained. Sensation was impaired over the feet with decreased pinprick and light touch. The feet were cool, pink, and sweaty. The knee flexed from 0 to 120 degrees, and both patellae were slightly hypermobile. The diagnostic assessment was chronic low back syndrome, with radicular pain down the right leg, reflex sympathetic dystrophy, disability of the right shoulder, mild cervical disc disease, and mild to moderate degenerative disc disease of the lumbar spine. The examiner expressed the opinion that the veteran had sustained a reflex sympathetic dystrophy or causalgia as the result of his crush injury in service with progressive impairment of gait. The examiner expressed the opinion that all of the veteran's problems could be traced back to this injury. A peripheral vascular examination resulted in the diagnosis of peripheral vascular disease. Vascular studies revealed diminished circulation at the level of the ankle bilaterally, right greater than left. X-rays of the right ankle revealed degenerative changes. Another statement was received from Dr. Abens dated in September 1996. Dr. Abens noted that CT scans and X-rays shortly after the November 1990 injury showed longstanding degenerative changes which had been brewing for many years. Dr. Abens stated that there was always a history of lumbar strain existing between 10 to 30 years when a person of the veteran's age shows such premature degenerative changes in the low back. Dr. Abens noted a history of acute lumbar strain in service, noting that it could be argued beyond a reasonable doubt that the veteran's low back "had to be" injured in the bus accident in service. Dr. Abens also noted that the he had observed the veteran limping for about 5 1/2 years. Dr. Abens believed that a significant portion of the veteran's low back condition related to the time he spent in service. A VA examination in September 1996 contained electromyogram studies which were negative, and which showed no evidence of radiculopathy. The physical examination resulted in the diagnosis of chronic back pain with no signs of lumbar radiculopathy. He had a nonanatomic sensory loss and some evidence of embellishment and apparent contrivance for the examination. Additional clinical records from the Midelfort Clinic were received in December 1996 covering the period between 1969 and 1983. It was noted that in January 1973 the veteran had been treated at a hospital for frostbite of the toes, right greater than left. In February 1973, he was seen for job training, with a notation that he was unable to do outdoor jobs. In November 1974, the veteran indicated that he had had a severe backache the previous night. In September 1981, he was provided a physical examination for a job at the Post Office. Physical examination was essentially normal. The back and extremities were noted as normal. In October 1983, the veteran complained of acute low back strain. A VA physician in February 1997 reviewed all the veteran's medical records, including service medical records, private medical records, and the results of the VA examinations. The physician expressed the opinion that the veteran's present low back disability was not related to the accident that occurred in service. He further stated that he did not believe that the veteran's "low back problems were caused by gait impairment resulting from the service-connected right knee and great toe injuries." He expressed the opinion that the low back problems were not aggravated by gait impairment resulting from the service-connected right knee or right great toe. As part of a detailed review of the veteran's medical history he noted that the VA examination in July 1968 showed that the veteran was able to walk without a limp, and that there was no significant limitation of the right ankle or right foot. The veteran did not have a significant low back problem at the time of discharge from service; with the first indications of low back pain in November 1974 being apparently acute in nature. He again had acute low back pain in October 1983. He apparently did not develop chronic symptoms in his low back until 1988 when he started to seek chiropractic treatment. He developed continuing low back and right leg pain only after the industrial accident in 1990. At a hearing before the Board in October 1997, the veteran testified about the pain in various joints, and about the accident in service. II. Analysis A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service. Watson v. Brown, 4 Vet. App. 309, 314 (1993). Service connection may be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Initially, it must be noted that the Board, and the Court in its decision of September 1999, determined that there was no direct causal connection between any current back disability and any inservice injury or incident. Both the Board and the Court cited the veteran's inconsistent statements relating to the nature of the original injury, and the inconsistency of the veteran's recent statements with more remote statements and contemporaneous medical records. However, the Court, in its decision, indicated that the Board had not properly adjudicated, with pertinent reasons and bases, the separate and distinct claim for secondary service connection for the current chronic disability of the low back. In 1991, Dr. Wolter indicated that he had treated the veteran for back, leg, and foot problems since June 1988. It was noted that the veteran tended to favor the right foot, that his gait had changed, and that this, in turn, had put stress on his lower back. It is noted, however, that Dr. Wolter did not have the benefit of the veteran's various medical records. He did not specify the etiology, date of onset, or cause of the gait impairment, or specifically link the gait impairment to the veteran's service connected disabilities. In the same way, Dr. Abens has provided several statements relating to the veteran's back and service-connected disabilities. It is noted, initially, that Dr. Abens started treating the veteran in 1991, and that the veteran provided a history at that time of being involved in a bus accident in service, with the bus running over the entire right side of his body. Dr. Abens did not have the benefit of the veteran's various records, including pertinent records in service, the post service VA examinations, or the medical records of the veteran's other private physicians. In essence, Dr. Abens has alternated theories as to the etiology of the veteran's back condition. Dr. Abens' statements indicate that the veteran's current back condition can be traced directly to the veteran's service, based on the veteran's history. The Board and the Court has dismissed this argument as previously discussed. In his statement in April 1991, Dr. Abens specifically indicated that he would ascribe 5 percent of the veteran's current back disability to a work-related injury that occurred in November 1990, 5 percent to previous work-related injuries, and 5 percent to the veteran's accident in service. There was no mention on this early April 1991 statement of any secondary causation resulting from the veteran's service-connected disabilities. In December 1991, Dr. Abens appears to have switched somewhat his medical opinion indicating that aberrant function in the right lower extremity caused additional wear and tear on the lower spinal column, causing the present lower back condition. He noted that recent X-rays showed degenerative changes and disc degeneration. For some reason, he did not mention that the disc bulging, degeneration, possible disc herniation, and arthritic changes were found only after an apparently significant on-the-job injury in November 1990. Dr. Abens stated that the veteran's right foot and right knee had been functionally aberrant since the service accident. He indicated that these two injuries, alone, had resulted in a great deal of physical disability. He stated that the "bogus right foot and knee" had caused undue stress on the lower back, which had resulted in degenerative changes. However, this statement of Dr. Abens in December 1991, again, did not indicate that he had reviewed the veteran's various medical records, but relied on the history provided by the veteran. From the clinical notes provided by Dr. Abens, a patient history shows that the veteran reported that he had been involved in an accident in service in which a bus ran over the entire right side of his body, and that he had had problems with his feet, legs, back, and shoulders since that accident. A review of the contemporaneous records show a quite different story. The veteran had no complaints involving his back on the separation physical examination in 1968, the VA examination in 1968, or the VA examination in July 1973. He did complain of an episode of back pain in January 1974, which was acute and transitory in nature, and another complaint of acute low back pain in October 1983, followed by a normal physical examination in 1984. Further medical records from the Midelfort Clinic show few, if any, complaints relating to the right lower extremity during the 1970's and early 1980's. In 1987, the veteran complained of back pain, which he stated was "chronic," and the veteran has mentioned at a hearing in 1993 that he had had podiatry treatments since the mid-1980's. The medical records from the Midelfort Clinic show that the veteran did complain of pain in the back and legs on a few occasions in 1987 and 1988, but physical examination later in 1988 showed only minimal disability in the right leg, with good muscle tone, and no indication of impaired gait. Thus, the basis for the December 1991 opinion from Dr. Abens, that the veteran had a long history of significant disability of the right knee and right foot after service, or the implication that he had a long standing gait impairment resulting from the severity of such service connected disabilities, is not supported by contemporaneous medical records. See Swann v. Brown, 5 Vet.App. 229, 232 (1993). Dr. Abens provided another statement in September 1996 noting that the veteran had been observed limping for about 5 1/2 years. Again, Dr. Abens seems to have switched his theory concerning the etiology of the veteran's chronic lumbosacral strain, indicating that, "it could be argued beyond reasonable doubt that the veteran's low back had to be injured in the bus accident" in service. It is further noted that Dr. Abens' clinical records note that the veteran provided the history that he had been run over in service by a bus, injuring his feet, legs, back, and shoulders, and that he had had problems with those areas of the body since the bus accident. The VA physician in February 1997 had the benefit of all of the medical records in the veteran's file. The VA physician expressly noted that there was no apparent limp in any of the medical records from the 1970's and 1980's. The examiner expressed the opinion that the veteran's current back problems, including low back strain and lumbar disc disease, were not caused by the veteran's injury in service, and were not caused by gait impairment resulting from the service-connected right knee and right great toe injuries. This is reinforced by the contemporaneous medical records showing that the veteran had problems with pain and numbness down the right leg following the industrial accident in November 1990, and Dr. Abens' own statements indicating that he had observed the veteran limping, but noting that he had treated the veteran only after such industrial accident. After reviewing these various medical opinions, the Board finds that the VA physician's opinion in 1997 is more persuasive than the statements from the veteran's chiropractors. In essence, Dr. Abens' statements are contradictory and clearly based on the history furnished by the veteran, without the benefit of a review of all of the veteran's records. The initial statement in April 1991 ascribed the veteran's back condition to industrial accidents and to service. This opinion concerning the service origin has already been discounted, and the claim based on such opinion has been denied. In addition, his subsequent statements are, in part, based on history provided by the veteran, which is not supported by the contemporaneous medical record. In fact, the contemporaneous medical records fail to show any indication of significant disability of the right knee or right foot for many years after service, until the 1990's. In addition, the contemporaneous medical records fail to show any indication of an altered gait before the industrial accident in 1990. The statement by Dr. Wolter in March 1991 did note some gait change which he ascribed to the veteran's right leg abnormalities, but that chiropractor did not have the benefit of the veteran's medical records. In addition, he did not indicate the etiology or cause of the gait impairment, or specifically link the gait impairment to the veteran's service connected disabilities. The veteran cannot rely on disability of the feet, the fallen arches or circulatory changes in the feet, causing the lumbosacral strain, since, presently, such disabilities which began several years after service, have not been service connected. Consequently, the present medical evidence is not persuasive that the veteran's service-connected right knee and right foot disability caused, or resulted in, the veteran's chronic low back disabilities of lumbosacral strain and lumbar disc disease. In addition, there has been no medical opinion or medical evidence to establish that the veteran's service-connected disabilities are aggravating the veteran's low back disabilities. See Allen v. Brown, 7 Vet. App. 439 (1995). As to the question of secondary service connection for disability of the feet, including circulatory problems in the feet and fallen arches (pes planus), the only opinion which provides some evidence of a causal relationship between such disabilities of the feet and the veteran's service-connected disabilities is the opinion of Dr. Abens in December 1991. In this regard, Dr. Abens stated that the veteran's service-connected disability of the right knee and right foot caused the veteran's low back disabilities, which, in turn, caused nerve interference in the right leg, causing circulatory problems and pes planus. However, the Board has just rejected the intermediate step in this causal relationship, indicating that disability of the lumbosacral spine is not service connected. Under such circumstances, any back disability which may have contributed, according to Dr. Abens, to circulatory problems and pes planus in the feet, is not service connected, and cannot be the basis for a grant of service connection for circulatory problems and pes planus in the feet. In addition, the February 1996 VA examination found that the longitudinal arches were preserved; a finding inconsistent with Dr. Abens' finding of fallen arches. In summary, there is no present medical opinion indicating that the veteran's service-connected disabilities are aggravating any circulatory problems or pes planus in the feet. See Allen v. Brown, supra. Therefore, the claim for service connection for disability of the feet is not established. ORDER Entitlement to service connection for a low back disability, including low back strain and lumbar disc disease, as proximately due to, or the result of service-connected disabilities is not established. Entitlement to service connection for foot disabilities, to include circulatory problems in the feet and fallen arches (pes planus), as proximately due to, or the result of service-connected disabilities is not established. The benefits sought on appeal are denied. ROBERT D. PHILIPP Member, Board of Veterans' Appeals