Citation Nr: 0000336 Decision Date: 01/06/00 Archive Date: 01/11/00 DOCKET NO. 97-16 130 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUE Entitlement to service connection for a vascular disability, claimed as secondary to residuals of a shell fragment wound (SFW) of the right thigh. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The veteran ATTORNEY FOR THE BOARD J.R. Bryant, Associate Counsel INTRODUCTION The veteran served on active duty from March 1944 to May 1946. This matter comes before the Board of Veterans' Appeals (Board) of the Department of Veterans Affairs (VA) on appeal from a February 1997 rating determination by the Huntington, West Virginia, Regional Office (RO) which denied service connection for vascular disability (characterized as peripheral vascular disease), claimed as secondary to residuals of a shell fragment wound of the right thigh. The veteran timely appealed that determination to the Board. FINDING OF FACT Although a VA physician opined that it was conceivable that there may be a relationship between the veteran's shell fragment wound and his vascular disability, the preponderance of the competent medical evidence of record indicates that no such relationship exists. CONCLUSION OF LAW A vascular disability is not proximately due to, or the result of, service-connected SFW residuals of the right thigh. 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. § 3.310(a) (1999). REASONS AND BASES FOR FINDING AND CONCLUSION Factual Background Service medical records show that on May 14, 1945 the veteran sustained a minor shell fragment wound to the right thigh. The wound was debrided and a small piece of fragment was removed. On June 8, the wound was considered healed and the veteran was released to duty the following day. In January 1991, service connection was established for SFW residuals of the right thigh and a noncompensable evaluation was assigned. Private treatment records dated from December 1983 to October 1990 primarily show treatment for disorders not currently at issue. These records are negative for complaints, findings or treatment associated with any vascular disability. In an August 1995 statement the veteran's wife reported that up until a few years ago, the veteran picked pieces of shrapnel out of his legs and now has poor circulation in his lower legs. She stated that the primary cause of the poor circulation was from his service connected right thigh injury. On VA examination in October 1995, the examiner noted in service the veteran's right thigh wound was allowed to heal by granulation, without suturing, following debridement and removal of the fragments. The veteran recently underwent femoral popliteal graft for arterial insufficiency of the right lower extremity. The clinical impression was residuals of shrapnel fragment wounds of the right thigh to include several scars and residuals of femoral popliteal graft of the right lower extremity. In a December 1996 statement, the veteran's mother-in-law stated that she witnessed the veteran "digging shrapnel out of his left arm." On VA examination in January 1997, the veteran reported that, since his original right thigh injury, he has picked shrapnel from the skin surface in his leg and foot. He reported that he subsequently began having lower extremity pain typical of claudication. He stated that it was difficult to do a full day's work and that he could not stand for prolonged periods. He complained of pain on walking and tightness in the calf. He indicated that he underwent femoral popliteal bypass graft several years ago that did not help much and that the condition has worsened. His medical history is significant for aortic valve replacement, carotid endarterectomy, congestive heart failure and thrombophlebitis and wound infection following the bypass surgery. Examination showed that the right leg was bigger than the left. There was a long scar extending from the right groin all the way to the ankle from the distal posterior tibial bypass from the femoral artery. The scar was thin and fine at the upper thigh but there was an area of granulation in the middle thigh and the scar was depressed and widened in the lower leg. The scar in the distal leg showed previous wound infection which and healed with secondary intension. The skin around this area was fibrotic and had evidence of healed ulcers. The foot appeared to be mildly cyanotic. The skin temperature appeared normally bilaterally. There was some tenderness along the scar in the lower leg. The shrapnel wound scars on the posterior aspect of the right thigh were well healed without tenderness or adhesions in the area. There were no shrapnel wound scars in the back of the leg or on the foot. The right calf was 44 centimeters and the left calf was 39 centimeters. The thighs were 64 centimeters bilaterally. The veteran's blood pressure was 158/58 and Doppler pressure in the lower extremities on the right side was 90 millimeters and on the left 110 millimeters. Femoral pulses were 3+ bilaterally. There were no distal pulses palpable, popliteal or at the ankle. There si no evidence of paresthesia. The diagnoses were moderately severe PVD, status post right femoral tibial bypass graft on the right side; history of thrombophlebitis with post- phlebitic syndrome right leg, congestive heart failure and history of aortic valve replacement. The examiner was unable to substantiate that the shrapnel wound on the posterior aspect of the thigh caused the veteran's PVD. The examiner stated it was conceivable that the wound might have damaged the collateral vessels that could have formed natural bypasses. X-rays revealed no evidence of any shrapnel present in the legs. In an April 1997 lay statement, the veteran's wife referred to an excerpt from the John Hopkins Medical Handbook that, in pertinent part, indicated that following surgery or sclerotherapy, blood reroutes itself into the healthy veins. She also contends that the veteran's shell fragment wound was a contributing factor in his vascular disease since the condition affects both legs but the right leg is worse than the left. In September 1997, the veteran testified at an RO hearing about the onset and severity of his vascular difficulties. He testified that he is not currently receiving treatment for vascular disease and that no physician told him specifically that his vascular disease is secondary to his SFW. The veteran testified that he believes his vascular disease is secondary to his service-connected SFW residuals because he has had right leg pain since service resulting in poor circulation and bypass surgery. Records from the Winchester Medical Center dated from October 1981 to March 1998 show treatment for various disorders including gastrointestinal bleeding; prostate problems; diabetes with a history of calf claudication, right greater than left; right femoral to posterior tibial artery at the ankle, insitu saphenous vein bypass; right endarterectomy and aortic valve replacement. In an August 1998 statement, the veteran's private physician, A. R. Tucker, III, M.D. reported the veteran presented in 1993 with poor circulation in both feet and underwent a right femoral to tibial bypass for salvage of his right leg. He subsequently underwent aortic valve replacement in 1995. In pertinent part Dr. Tucker stated the veteran's problems with peripheral and cerebrovascular insufficiency were related to his history of obesity and cigarette abuse. VA outpatient treatment records show treatment for diabetes, arteriosclerotic heart disease, peripheral vascular disease, hypertension, obesity and gastrointestinal bleeding. On VA examination in November 1998, both legs up to the level of mid-calves showed discoloration and fibrotic changes of the skin with swelling and hardening of the skin, all secondary to old phlebitis. There was no evidence of skin ulcer secondary to thrombophlebitis noted in either legs. The feet were warm bilaterally and the color is slightly bluish, worse on the right side. The capillary circulation in both lower extremities was good. Circumference of both mid-thighs was equal at 65 centimeters. Due to thickening of the skin, pedal pulses were hard to palpate but ankle Doppler pressure on the right side showed 100 and on the left 110. Auscultation of the saphenous bypass graft on the right side with Doppler showed good flow in the graft. The scar in the mid calf was painful and slightly tender in manipulation. There was no evidence of paresthesia at the site of this scar noted. X-rays of the right lower extremity showed clips associated with the bypass surgery. The examiner concluded the veteran had generalized arteriosclerotic disease involving peripheral vessels and carotid arteries resulting in a right femoral posterior tibial bypass surgery and carotid endarterectomy. He also indicated that the veteran had residual chronic thrombophlebitis with post phlebitic syndrome involving both lower extremities. The shrapnel wound was superficial and located in the posterolateral aspect of the right upper thigh. It was not close to any major vessels and X-rays did not show residual shrapnel fragments. The examiner concluded the atherosclerotic disease of the lower extremities with residual bilateral thrombophlebitis syndrome was not related to the superficial shrapnel wound in the posterolateral aspect of the right thigh. Analysis The law permits the grant of service connection for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110. Service connection may be granted for a "[d]isability which is proximately due to or the result of a service-connected disease or injury. .. " 38 C.F.R. § 3.310(a) (1996); Harder v Brown, 5 Vet. App. 183, 187-89 (1993). That regulation has been interpreted to permit service connection for the degree of disability resulting from aggravation to a nonservice- connected disorder by a service-connected disorder. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). The veteran does not contend, and the evidence does not suggest, that the veteran's PVD had its origins in service. Rather, the veteran has alleged that his PVD is in some manner etiologically or causally related to his service- connected right thigh disability. When a veteran contends that his service-connected disability had caused a new disability, he must submit competent medical evidence of a causal relationship between the two disabilities to establish a well-grounded claim. Jones (Wayne L.) v. Brown, 7 Vet. App. 134 (1994). In this case, a January 1997 VA physician has suggested the possibility of a relationship between the service-connected shell fragment wound and the veteran's circulatory difficulties. The Board finds that this opinion is sufficient to render the claim at least plausible and, hence, well grounded. See 38 U.S.C.A. § 5107(a) (West 1991 & Supp. 1999); Murphy v. Derwinski, 1 Vet.App. 78, 81 (1990). However, the remainder of the competent medical evidence relevant to this question militates against the veteran's claim. As noted above, in an August 1998 statement, Dr. Tucker, the veteran's own physician indicated that the veteran's problems with peripheral and cerebrovascular insufficiency were related to his history of obesity and cigarette abuse; he did not mention the veteran's service- connected shell fragment wound. Even more poignant, in a detailed medical opinion, a November 1998 VA examiner specifically ruled out a relationship between the superficial shrapnel wound of the right thigh and the veteran's atherosclerotic disease of the lower extremities with bilateral thrombophlebitis syndrome. As the Board finds that the latter, more definitive private and VA physician opinions outweigh the speculative January 1997 medical opinion the Board also must conclude that the preponderance of the relevant and competent medical evidence of record is against the claim. The Board does not doubt the sincerity of the beliefs of the veteran, his wife, and his mother in law as to a relationship between the veteran's SFW and his vascular difficulties. However, none has the medical training or expertise to render a probative opinion on a medical matter, such as the etiology of a disability. As such, although the lay testimony and allegations of entitlement (including references to medical treatise evidence) have been considered, such is not competent evidence of causality or aggravation to support the secondary service connection claim. See Jones v. Brown, 7 Vet. App. 134, 137 (1994); Espiritu v. Derwinski, 2 Vet. App. 492, 494-5 (1992). In reaching the above determination, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b) (West 1991); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1991). ORDER The claim for service connection for vascular disability secondary to the service-connected SFW residuals of the right thigh is denied. JACQUELINE E. MONROE Member, Board of Veterans' Appeals