Citation Nr: 0000252 Decision Date: 01/05/00 Archive Date: 03/02/00 DOCKET NO. 96-12 508 DATE JAN 05, 2000 On appeal from the Department of Veterans Affairs Regional Office in Hartford, Connecticut THE ISSUE Entitlement to service connection for Morton's neuromas of both feet secondary to service-connected dermatophytosis. REPRESENTATION Appellant represented by: AMVETS WITNESSES AT HEARINGS ON APPEAL The veteran and XXXXXXX XXXXXXXX ATTORNEY FOR THE BOARD C. Fetty, Associate Counsel INTRODUCTION The veteran had active service from October 1954 to September 1957. This appeal arises from a July 1996 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Hartford, Connecticut, which. denied a claim for service connection for Morton's neuromas of both feet secondary to service- connected dermatophytosis. The veteran has appealed to the Board of Veterans' Appeals (Board) for favorable resolution. A September 1996 VA Form 646 contains a notice of disagreement. The RO issued a statement of the case in June 1999 and the veteran submitted a substantive appeal in June 1999. The veteran has not requested a hearing,on this matter. However, relevant testimony was given during hearings on another issue during the appeal period for this issue. FINDINGS OF FACT 1. All evidence necessary for an equitable determination of the issue has been obtained by the RO. 2. Morton's neuroma was not present in service or for many years after and is not related to an incident of service or to a service- connected disability. CONCLUSION OF LAW Morton's neuromas of both feet were not incurred in or aggravated by active service or service-connected disability, nor may this disability be presumed to have been 2 - incurred in active service. 38 U.S.C.A. 1101, 1110, 1112, 1113, 1131, 1137 (West 1991 & Supp. 1999); 38 C.F.R. 3.303, 3.307, 3.309, 3.310 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION Initially, the Board finds that the veteran's service connection claim is well grounded. The veteran has submitted medical evidence of a current diagnosis of Morton's neuroma, evidence of incurrence of a foot disorder during active service, lay evidence of continuity of symptomatology, and an opinion of a physicians assistant (PA) tending to relate present conditions to symptoms experienced during active service, thus providing a plausible basis for the claim. However, the establishment of a plausible claim does not dispose of the issue. The Board must review the claim on its merits and account for the evidence that it finds to be persuasive and unpersuasive and provide reasoned analysis for rejecting evidence submitted by or on behalf of the claimant. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. See Alemany v. Brown, 9 Vet. App. 518 (1996), citing Gilbert, at 54. The Board finds that all relevant evidence for equitable disposition of this claim has been obtained to the extent possible and that no further assistance to the veteran is required to comply with VA's duty to assist him. See 38 U.S.C.A. 5107(a) (West 1991). I. Factual Background Information from the Army indicates that the veteran served with the Infantry in the Panama Canal Zone during active service. Although he served during the Korean Conflict, the record does not indicate that he served in Korea or that he had any combat service. The veteran's service medical records (SMRS) indicate that he was treated for athlete's foot and for dermatophytosis several times during active service in the Canal Zone. Left heel cellulitis was noted on one occasion. These foot conditions - 3 - were treated with foot soaks, fungicide, orthotic arch supports, and restriction from wearing boots. The SMRs are negative for any neuroma of the feet. A November 1957 VA special dermatology examination report notes erythema on the soles and ankles. During the examination, the veteran reported that when his feet perspired while working, they itched and became cold and numb. The report does not note any complaint of foot pain or burning sensation. The RO subsequently established service connection for dermatophytosis of the feet. According to a December 1978 report, the veteran was treated privately for complaint of back pain in September 1978. The report contains no mention of any foot complaint. A February 1989 private magnetic resonance imaging (MRI) study of the feet showed no bone, joint or soft tissue abnormality. A March 1989 private report from Dr. Richard Campbell-Jacobs indicates that the veteran reported that his feet had ached for three years. The doctor opined that the symptoms seemed to be related to the veterans shoe wear, noting that the veteran reported that when he went barefoot over the weekend, his symptoms subsided. The doctor noted that the plantar heels seemed to be in pain that day as opposed to the balls of the feet. The veteran was referred to Dr. Daniel C. Belin. Dr. Belin examined the veteran's feet in May 1989. During that examination, the veteran reported that knee pain began at work about two years earlier and since that time excessive standing caused knee pain and foot pain as well. Dr. Belin examined the veteran's feet and noted that they were not tender (in spite of complaints of pain while standing at work), that the pulses were good, and that the toes were down- going, bilaterally. A clinical record from the veteran's employer dated in September 1989 indicates that he complained of pain in his feet and his knees; however, he related his symptoms to a November 1987 injury. 4 - VA treatment reports dated in the 1990s note complaint of foot pain since active service. A February 1990 VA treatment report indicated that the veteran complained of bilateral plantar burning which began in 1953 and progressed to posterior calf burning, pain, and trauma. The assessment was probable tarsal tunnel syndrome questionably related to root neuropathy. Dr. Arthur L. Waldman, a private neurologist, examined the veteran in February 1990. Dr. Waldman reported that the veteran had a three-year history of burning pain and numbness in his feet. Dr. Waldman noted that the onset of the pain coincided with a job change in the 1980's that involved more standing and walking. Dr. Waldman noted that the veteran had difficulty curling the toes of both feet, especially the left, and that there was interosseous atrophy of the sole of the left foot. The doctor opined that the veteran's symptoms were compatible with plantar digital nerve compression of the feet and that causative factors probably included standing on the feet at work and perhaps some weight gain. In March 1990, Dr. Waldman opined that with reasonable medical probability the veteran's present difficulty with his feet (plantar digital neuropathy) was related to a change in his gait caused by a November 1987 knee injury. Dr. Marita Malone examined the veteran in November 1990. During this examination, the veteran complained of considerable foot pain at work. He reported burning in his feet that went up his calves. He again related that his foot pain began in 1987 and was related to standing on a hard floor at work and knocking his knee into some machinery. Dr. Malone noted that the veteran walked normally and that his ankles and feet were unremarkable with good pulses. She treated him for pes anserinus syndrome and noted a week later that it was medically possible that the condition could be caused by continuous friction and irritation of the knee rubbing against machinery. 5 - In January 1995, the veteran reported that he has experienced the same burning sensation in his feet that began during active service. He submitted private medical reports that note complaints of "burning feet" and treatment during the 1990s. In October 1995, Dr. David Unger, Jr., examined the veteran and noted that the veteran reported a long history of burning feet related to athlete's foot in service. Dr. Unger felt that the veteran was an unreliable informant and further noted that the pain was felt in the balls of the feet and subsided when the veteran was off his feet and could remove his shoes. Intermetatarsal pain was found on palpation. Dr. Unger suspected neuromas and ordered ultrasound tests. The October 1995 ultrasound report showed abnormal structures consistent with bilateral Morton's neuromas and it was also felt that the veteran had bilateral tarsal tunnel syndrome. The doctor did not relate these conditions to the veteran's reported history of athlete's foot. The veteran testified before an RO hearing officer concerning another issue in February 1996. He testified that he reported his foot pain soon after separation from active service but that his complaints were not recorded because no one could find anything wrong with his feet. He testified that began working for Pratt & Whitney in about 1983 and that their records indicated that he complained of foot pain in 1985. In June 1997, the veteran testified before the undersigned member of the Board concerning an issue that has already been decided. He testified that his foot pain began in 1954 and was the same pain that he currently felt, although the pain was worse currently. Because of the similar foot pain, he concluded that Morton's neuromas began during service. Michael O'Rourke, PA, testified to the effect that after listening to the veteran's reported history of continuous foot pain since active service, he felt that Morton's neuromas was a chronic condition. He agreed with earlier statements that there was no diagnosis of the condition prior to a recent opinion of a physician. He noted that - 6 - prior to the recent diagnosis, there was not even a differential diagnosis as to what could cause the foot pain. In October 1997, the Board remanded the case to the RO for a search for any additional treatment reports addressing the feet. In the remand, the Board directed that if any treatment reports supported the veteran's increased rating claim, then the veteran should be afforded a VA examination to determine the nature and etiology of any foot conditions. Any report received subsequently did not support the claim and he was therefore not scheduled for further VA examination. Most of the clinical reports received by the RO since that time chiefly concern treatment for a rotator cuff injury and, in any event, do not provide any additional information on the etiology of Morton's neuromas. In July 1998, the RO received SSA records that include records from the veteran's employer during the 1980's and 1990's reflecting medical evaluation for various health problems, including complaints of foot pain. None of the reports relates any current foot condition to active service or to a service-connected foot disorder. II. Legal Analysis Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. See 38 U.S.C.A. 1131 (West 1991); 38 C.F.R. 3.303 (1999). A chronic disease will be considered to have been incurred in service when manifested to a degree of 10 percent or more within 1 year from the date of separation from active service. See 38 C.F.R. 3.307 (1999). Organic disease of the nervous system shall be considered a chronic disease within the meaning of 38 C.F.R. 3.3 07. See 38 C.F.R. 3.309 (1999). Determinations regarding service connection are to be based on review of the entire evidence of record. See Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991); 38 C.F.R. 3.303(a). Disability that is proximately due to or the result of a service-connected disease or injury shall be service connected. See 38 C.F.R. 3.310(a)(1999). 7 - In cases involving a question of medical causation, competent medical evidence is required to link directly or secondarily the claimed condition to the veteran's period of active service. See Lathan v. Brown, 7 Vet. App. 359, 365 (1995); Caluza v. Brown, 7 Vet. App. 498,,506 (1995); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Review of the evidence on the merits indicates that the veteran has reported that his foot pain began during active service and has increased since active service. The veteran sincerely feels therefore that his Morton's neuromas have existed since active service along with service-connected dermatophytosis. A PA has opined that the veteran's reported history of chronic foot pain since active service and more recent diagnosis of Morton's neuromas indicates a possible link between the reported symptoms and the current diagnosis and hence, a possible link to active service. The Board agrees that these contentions do support the claim to at least some extent. On the other hand, the private medical opinions of record do not tend to relate Morton's neuromas to active service or to the service-connected foot disorder. Moreover, these private medical reports contain persuasive evidence that intercurrent causes are responsible for the Morton's neuromas. According to the private medical reports, the first of the current foot pain complaints arose in or around 1987, three decades after active service. In 1990, Dr. Waldman noted that the onset of foot pain coincided with a job change that involved more standing and walking. Dr. Waldman also felt that with reasonable medical probability, the plantar digital neuropathy was related to a change in gait caused by a 1987 knee injury. In 1995, Dr. Unger noted that the veteran felt that his burning foot symptoms were related to his athlete's foot. Dr. Unger noted that the veteran's explanation was inconsistent with his symptoms because the veteran was also reporting at the time that his foot pain subsided when he was off his feet. Dr. Unger then suspected Morton's neuromas and ordered ultrasound tests, which confirmed his suspicion. Thus, the Board finds that the private medical evidence indicates that job changes and increased stress on the feet in the late 1980's resulted in Morton's neuromas, - 8 - which were first diagnosed in 1995. One doctor even related the increased stress on the feet to a change in gait that itself was caused by an on-the-job knee injury in 1987. The Board notes that these physicians have each treated or examined the veteran and have based their opinions on reasonably correct factual history. While the veteran has reported that he has had foot pain continuously since service, the doctors have reported that the foot pain began in the 1980's and the record does not otherwise support the veteran's complaint of continuous foot pain since service. Assuming arguendo that the veteran did have continuous foot pain since active service, that fact still does not carry the weight of competent medical opinions relating Morton's neuroma to other causes. The veteran's theory of causation, although plausible, cannot carry the weight that a medical professional's opinion carries when there is no other reason to doubt the medical opinion. Moreover, when the veteran is offering an opinion on a medical issue such as the etiology of a medical condition, the Board cannot accord it any weight at all. See Espiritu v. Derwinski, 2 Vet. App. 492, 494-5 (1992). As to the PA's testimony, the Board points out the PA did not specifically relate Morton's neuromas to a service-connected fungal condition (as the veteran contends), but merely agreed that the foot pain was chronic. The PA has not treated the veteran and has relied on a history of Morton's neuromas that the Board specifically rejects. Upon weighing the favorable evidence against the unfavorable evidence, the Board finds that the preponderance of it is unfavorable to the claim. The Board also finds that the veteran did not serve in combat. Therefore, his testimony does not receive the special deference accorded under testimony does not receive the special deference accorded under 38 U.S.C.A. 1154(b) (West 1991). After consideration of all the evidence of record, including the testimony of record, the Board finds that the preponderance of it is against the claim for service connection for Morton's neuromas of both feet secondary to service-connected dermatophytosis. Indeed, the veteran's contentions together with the PA's nexus opinion do not weigh nearly so heavily as the opinions as to etiology supplied by the private physicians. Because the preponderance of the evidence is against the 9 - claim, the benefit of the doubt doctrine is not for application. 38 U.S.C.A. 5107(b) (West 1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1991). ORDER The claim for service connection for Morton's neuromas of both feet secondary to service-connected dermatophytosis is denied. J.E. Day Member, Board of Veterans' Appeals - 10-