Citation Nr: 0006286 Decision Date: 03/08/00 Archive Date: 03/17/00 DOCKET NO. 95-35 110 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston- Salem, North Carolina THE ISSUES 1. Entitlement to an increased rating for pes planus, currently evaluated as 10 percent disabling. 2. Entitlement to an increased (compensable) rating for hemorrhoids. 3. Entitlement to an increased rating for cavernous hemangioma of the left lower extremity, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: North Carolina Division of Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A. Shawkey, Counsel INTRODUCTION The veteran served on active duty from May 1975 to November 1975 and from January 1977 to January 1983. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an April 1995 decision of the Department of Veterans Affairs (VA) regional office (RO) in Winston-Salem, North Carolina, that assigned 10 percent ratings for cavernous hemangioma of the left lower extremity and for pes planus, and denied a compensable rating for hemorrhoids. In July 1997 the veteran appeared and testified at a Travel Board hearing conducted by C. W. Symanski, a member of the Board who is responsible for making a determination in this case. See 38 C.F.R. § 20.707. This case was subsequently before the Board in February 1998 and January 1999 at which times it was remanded to the RO for further development. FINDINGS OF FACT 1. The veteran's pes planus is manifested primarily by borderline valgus deformity and pain that produce no more than moderate impairment; symptoms productive of severe functional impairment including marked deformity and characteristic callosities are not found. 2. The veteran's hemorrhoid disability is no more than moderate in degree and is not productive of large or thrombotic hemorrhoids that are irreducible and have excessive redundant tissue, evidencing frequent occurrences. 3. The veteran's cavernous hemangioma of the left popliteal area is productive of limitation of motion to a minimal degree and functional loss due to pain. CONCLUSIONS OF LAW 1. The criteria for a rating greater than 10 percent for bilateral pes planus have not been met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.71a (Diagnostic Code 5276) (1999). 2. The criteria for a compensable rating for hemorrhoids have not been met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.114 (Diagnostic Code 7336) (1999). 3. The criteria for a rating greater than 10 percent for cavernous hemangioma of the left popliteal area have not been met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. §§ 4.71a (Diagnostic Codes 5260-6), 4.73 (Diagnostic Code 5328), 4.118 (Diagnostic Code 7805) (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual Background The veteran's service medical records include physical profiles for cavernous hemangioma in the left popliteal area and for pes planus. They also include the veteran's complaint in October 1981 of having had hemorrhoids off and on for three months. Findings at that time revealed a four to five millimeter internal hemorrhoid. The veteran was prescribed a suppository and sitz bath. In April 1984 the RO granted service connection for hemorrhoids, pes planus and cavernous hemangioma, assigning each disability a noncompenable rating. In February 1993 the veteran filed a claim for increased ratings for hemorrhoids, pes planus and cavernous hemangioma. In April 1994 the veteran was seen at a VA medical facility complaining of problems with a tumor behind his left knee. Findings pertaining to the posterior part of the left knee revealed vascular, soft swelling. The veteran was diagnosed as having hemangioma behind the left knee. At a VA examination in July 1994, the veteran reported entering service with a very small prominent blood vessel behind his left knee which gradually enlarged, becoming sore to touch. He said that he experienced continued tenderness in this area and achiness. On examination the skin was normal in appearance except for prominent reddish blue plexus vessels which had the appearance of a cavernous hemangioma. The area measured 4 centimeters by 4 centimeters and was approximately round in configuration. It was tender to touch with some increased temperature over the surrounding area. The knee joint itself appeared normal and was not tender to touch and exhibited full range of motion and stability. The veteran was given a diagnosis of cavernous hemangioma left popliteal area, symptomatic. An X-ray report in July 1994 shows there was no significant pathological findings of the left knee. Also in July 1994 the veteran underwent a VA examination for his feet and reported experiencing an aching from the feet into the ankle. He did not report swelling. He walked with a somewhat anatalgic gait and his feet appeared symmetrical. He had prominent convexity along the medial aspect of the sole, medial longitudinal arch typical of flat foot. He did not have tenderness on squeezing the metatarsals or on stretching, flexing or extending ligaments of the foot or the ankle. His skin was normal. In conducting range of motion studies, the veteran could dorsiflex to 20 degrees and plantar flex without pain to 40 degrees. The veteran was diagnosed as having bilateral pes planus that was moderately severe with right and left metatarsalgia. A July 1994 VA X- ray report of the veteran's feet showed that minimal early pes planus bilaterally could not be ruled out. In regard to hemorrhoids, the veteran presented to a VA examination in July 1994 where he reported having a history of hemorrhoids which in the past involved swelling and soreness on occasion. He said that he had tenderness which came and went and made him feel as if it "would stop him up". The veteran gave no history of bleeding, weight loss or other systemic symptoms. On examination there were no hemorrhoids seen or felt. The veteran was not tender about the rectum or anus. He was diagnosed as having history of hemorrhoids, not found on examination. The examiner stated that the veteran's symptoms as elicited and findings did not indicate any particular worsening of any of the veteran's conditions. In April 1995 the RO increased the veteran's noncompensable ratings for pes planus and cavernous hemangioma of the left lower extremity to 10 percent disabling, and continued the noncompensable rating for hemorrhoids. In a September 1995 substantive appeal, the veteran stated that his cavernous hemangioma was 2 x 2 inches as opposed to its prior size in service of 4 centimeters. He said that this tumor gave him great pain which occurred at any time. He said that he had problems with standing and walking and did not have full range of motion. He also said that he had not been treated for any of his complaints. In regard to his feet, the veteran said that he had reported to a VA medical facility in August 1995 due to joint pain of the hands, legs and feet. With respect to hemorrhoids, the veteran said that he had reported to VA doctors that the hemorrhoids stopped his bowel movements. He said that he was never given treatment or medication by VA for this condition. A March 1996 VA consultation report notes that the veteran was service-connected for a hemangioma of the left leg that was symptomatic and needed chronic follow up. The veteran's primary complaint at that time was achiness in all joints. The veteran also said that he had hemorrhoids at times that were painful and interfered with bowel movements. He underwent a rectal examination which did not reveal any hemorrhoids. Examination of the veteran's skin revealed a 2 x 2 inch growth behind the left knee. Examination of the veteran's rectum at a VA primary care clinic in January 1997 revealed no hemorrhoids. At a Travel board hearing before C.W. Symanski in July 1997, the veteran testified that he had pain and soreness in the area of his cavernous hemangioma of the left lower extremity and that on a scale of 1 to 10 with 10 being the worst, the pain was at least an 8 or 9. He said that the area itched and was moist. He said that he took pain medication for this condition. He said that the area burned and stung whenever it got wet. He also said that the condition made him limp and that he did not have full movement of his leg. With respect to pes planus, the veteran said that both feet hurt and that on a scale of 1 to 10 the pain was an 8. He said that his feet hurt more after periods of walking or standing than at rest and that he could only walk two blocks before having to stop because of pain. He said that he wore over- the-counter insoles which did not help as much as they had in the past, and that VA had not prescribed any type of orthopedic appliance for him to wear. He said that his feet hurt more presently than they had in service. He said that he had calluses or dead skin on his feet, especially around his big toe and the top of his feet. In regard to hemorrhoids, the veteran said that they itched and were sore and blocked his bowel movements. He denied having had much blood or undergoing surgery for his hemorrhoids. He said that they protruded almost all of the time. He said that the hemorrhoids gave him some pain on sitting and that they became irritated when getting up and walking around the house. He said that he used an over-the-counter medication which helped a little. In July 1998 the veteran underwent a VA examination for hemorrhoids. He complained that his hemorrhoids stayed swollen, prolapsed and blocked off so that he could not have a bowel movement easily. He denied a history of bleeding, but said that there was soreness, rawness and itching. He said that he used suppositories. Digital rectal examination was unremarkable. There was adequate spincter tone and no immediate complications. The examiner said that the veteran's history was entirely consistent with internal hemorrhoids which tended to prolapse, but that this could not be proven based on the examination at that time. The examiner also relayed the veteran's report of having recently undergone a sigmoidoscopic examination at the VA medical center in Durham, North Carolina. He diagnosed the veteran as having history of hemorrhoids, perhaps prolapsing, normal examination on that date. Findings related to a VA examination of the veteran's cavernous hemangioma in July 1998 show that the lesion was irregularly shaped and measured approximately 1.75 inches in its dimensions. On palpation the lesion was slightly tender and "squishy". The veteran was noted to tend to hold his knee in flexion of about 5 degrees; however, he could straighten it out without significant difficulty. Range of motion was from 0 to 140 degrees. There was no instability of the joints. The veteran was able to squat to the floor and come back up. He could walk on his toes and heels. He was diagnosed as having hemangioma of the left thigh posterior muscle near the popliteal fossa. The examiner remarked that lesions of that kind tended to be much more extensive than they appeared and that surgical procedures to correct them were more apt to make the condition worse than help it. He said that it was for this reason that the veteran had not had surgery. Pictures taken of the cavernous hemangioma in July 1998 show that it is located on the back of the veteran's left leg just above the knee. At a VA examination for pes planus in July 1998, the veteran gave a history of foot pain which was worse on the bottom of the toes and around the heels. He said that this kept him from walking any significant distances. He said that his feet hurt after walking half of a block and that his legs hurt constantly. Findings revealed no instability of the feet and no edema. There were no specific tender areas and no vascular changes. Circulation appeared adequate. There was no significant valgus deformity of the foot. The veteran was diagnosed as having bilateral flatfoot. X-rays taken of the veteran's feet by VA in July 1998 reveal borderline hallux valgus deformity of the left foot with no associated degenerative changes and borderline midfoot drop of the right foot. A left knee X-ray taken in July 1998 was normal. In an addendum opinion in August 1998, the examiner who performed the July 1998 examinations said that the veteran had slightly sagging longitudinal arches bilaterally and could walk on his toes and heels. He said that physical examination of the feet was basically normal, except for the sagging of the arches. He said that the problem was a subjective one in that the veteran felt that he could not use his feet any more than was indicated on the original examination report. He said that any further discussion would require unwarranted speculation. In a September 1998 addendum report, the VA examiner stated that the veteran had demonstrated full range of motion of the knee which was stable. He added that the veteran had a tendency to not fully extend the knee, but that it would extend fully. He said that the nature of the cavernous hemangioma of the veteran's sort was that it tended to be infiltrative, invasive and could very likely cause some symptomatology. However, he said that the basic problem was a subjective one of pain and that the veteran stated that he had pain all the time. The examiner said that to further comment on the symptomatology of the findings would require unwarranted speculation on his part. In January 1999 the RO requested a copy of a sigmoidoscopic examination report from the VA medical center in Durham. In April 1999 the veteran was again examined by the same examiner who performed the July 1998 examinations. In regard to his feet, the veteran reported swelling at times and denied using any aids to ambulate. Findings included discomfort on palpation across the transverse arch (distal ends of the metatarsals). There were no callosities or other dermal evidences of pressure or problems with mechanics of the foot. When the veteran stood, there was slight sagging of the arches bilaterally. The veteran was able to walk on his toes but stated that it was painful because of pain in the forefoot. He was also able to walk on his heels. He was diagnosed as having sagging arches bilaterally. There was no evidence of callosities or other problems of that nature. An X-ray examination was not repeated. Examination in April 1999 of the veteran's cavernous hemangioma showed it to be a mildly tender and irregularly shaped subcutaneous hemangioma which was approximately 2 x 2 inches. It was not in the lower leg, but was in the thigh on the left. The veteran protected the left knee joint slightly when he did a full knee bend and lacked 10 degrees of full flexion of the left knee. There was slight discomfort on passive flexion of the left knee and no discomfort to 120 degrees. Extension lacked 5 degrees of full extension. The veteran was diagnosed as having hemangioma involving the posterior distal thigh. A digital rectal examination performed in April 1999 was normal except for an enlarged firm prostate without any dominant nodules. The veteran was given a diagnosis of hemorrhoids not found on examination. The examiner said that the requested material from Durham regarding a sigmoidoscopic examination done approximately one year earlier had not been forthcoming. Photographs of the veteran's cavernous hemangioma and his feet were taken at the April 1999 examinations and have been associated with the veteran's claims file. II. Legal Analysis The veteran's claims for increased ratings for a cavernous hemangioma in the left popliteal area, pes planus and hemorrhoids are well grounded, meaning plausible. The file shows that the RO has properly developed the evidence, and there is no further VA duty to assist him with his claims. 38 U.S.C.A. § 5107(a). In this regard, an attempt was made by the RO in January 1999 (pursuant to a February 1998 Board remand order) to obtain a copy of a sigmoidoscope examination report from the VA medical center in Durham, North Carolina. This request stems from the veteran's report at a 1998 examination of having recently undergone such an examination at that facility. In responding to this request, the Durham VA medical center stated that it had transferred the veteran's chart to the Fayetteville VA medical center and would thus forward VA's request to the Fayetteville facility. The VA medical center in Fayetteville subsequently forwarded treatment records to the RO, but such records do not include a sigmoidoscope examination report. In view of this attempt, as well as a previous request to the Fayetteville VA medical center in February 1998 for all pertinent treatment records, VA's duty to assist the veteran with his claim is deemed satisfied. Furthermore, the evidence on record pertaining to the veteran's hemorrhoid disability, to include two recent VA examinations performed in 1998 and 1999, constitutes sufficient evidence in which to properly rate this disability. Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. The history of the veteran's disabilities has been considered, although it is the present level of disability that is of primary concern in determining whether he is entitled to higher evaluations. Francisco v. Brown, 7 Vet. App. 55 (1994). Pes Planus Pes planus is evaluated under 38 C.F.R. § 4.71a, Diagnostic Code 5276. Under this code a 10 percent rating is warranted for bilateral pes planus which is moderate, with the weight- bearing line over or medial to the great toe, inward bowing of the tendo achilles, pain on manipulation and use of the feet, bilateral or unilateral. A 30 percent evaluation is warranted when bilateral pes planus is severe, with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. At a VA examination in 1994, the veteran was diagnosed as having bilateral pes planus that was "moderately severe" with right and left metatarsalgia. While this diagnosis suggests a rating somewhere between 10 percent for "moderate" pes planus and 30 percent for "severe" pes planus, subsequent examinations and associated findings show that the disability most approximates the present 10 percent rating for moderate impairment. In an addendum opinion in September 1998, a VA examiner stated an examination of the veteran's feet in July 1998 had been basically normal except for sagging of the arches. A finding of slight sagging of the arches was also noted at a VA examination in April 1999. This finding, along with X-ray findings in July 1998 of borderline hallux valgus deformity of the left foot and a medical opinion that there was no significant valgus deformity of the foot, does not show marked deformity as is required for a 30 percent rating. Rather, these findings best analogize the lesser criteria for a 10 percent rating requiring the weight-bearing line over or medial to the great toe and inward bowing of the tendo achilles. The criteria for a 30 percent rating also requires an indication of swelling on use and characteristic callosities. In this regard, there was no evidence of callosities or other problems of that nature at a VA examination in April 1999, nor was swelling or callosities noted at the 1998 examination. Moreover, the finding in 1999 of "discomfort" on palpation across the transverse arch is most consistent with pain on manipulation as opposed to pain on manipulation accentuated. For the reasons stated above, the preponderance of the evidence is against the veteran's claim for a rating greater than 10 percent for bilateral pes planus. 38 C.F.R. § 4.71a, Diagnostic Code 5276. As such, the benefit of the doubt doctrine is not for application and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Hemorrhoids External or internal hemorrhoids with persistent bleeding and with secondary anemia, or with fissures, warrant a 20 percent rating. Large or thrombotic hemorrhoids that are irreducible and have excessive redundant tissue, evidencing frequent recurrences, are rated 10 percent. Hemorrhoids which are mild or moderate warrant a zero percent evaluation. 38 C.F.R. § 4.114, Code 7336. Although the veteran's hemorrhoid disability is symptomatic at times, as indicated by his complaints that his hemorrhoids prolapse and block his bowel movements, and are sore and itchy, the condition is not more than moderate in degree, properly rated noncompensable under Code 7336. This is so in view of the lack of showing of large or thrombotic, irreducible hemorrhoids, with excessive redundant tissue, evidencing frequent occurrences. In fact, the postservice medical records fail to document any hemorrhoids at all. Such evidence includes digital rectal examinations performed in July 1994, January 1997, July 1998 and April 1999, all which failed to find any hemorrhoids. Consequently, the criteria for a compensable (10 percent) rating are not met. As the preponderance of the evidence is against the veteran's claim, the benefit of the doubt doctrine is not applicable, the claim for a compensable rating for service-connected hemorrhoids must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Carvernous Hemangioma The veteran is currently rated as being 10 percent disabled under 38 C.F.R. § 4.73, Diagnostic Code 5328, for muscle neoplasm of, benign, postoperative. Under this code, the disability is to be rated on impairment of function, i.e., limitation of motion, or scars, diagnostic code 7805, etc. Under diagnostic code 7805, scars other than those that are superficial are to be rated on limitation of function of the part affected which in this case is the left leg. 38 C.F.R. § 4.118. Pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5260, limitation of motion of the leg warrants a 0 percent rating for flexion limited to 60 degrees and a 10 percent rating for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees and a 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. For limitation of extension of the leg, a 0 percent rating is warranted for extension limited to 5 degrees, a 10 percent rating is warranted for extension limited to 10 degrees, a 20 percent rating is warranted for extension limited to 15 degrees, and a 30 percent rating is warranted for extension limited to 20 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. The veteran demonstrated full range of motion of the lower extremities at VA examinations in July 1994 and July 1998. See 38 C.F.R. § 4.71a. Plate II. At a VA examination in April 1999, he demonstrated flexion to 120 degrees and loss of extension of 5 degrees in the left leg. Id. Based on strict adherence to the range of motion codes, these findings approximate a noncompensable rating under Code 5261 for extension limited to 5 degrees, and do not approximate a compensable or even a noncompensable evaluation under Code 5260 for limitation of flexion to 120 degrees. However, in evaluating this disability consideration must also be given to a higher rating based on limitation of motion due to pain on use or during flare-ups. 38 C.F.R. §§ 4.40, 4.4, 4.59; Deluca v. Brown, 8 Vet. App. 202 (1995). The veteran testified in July 1997 that he had pain in the area of the cavernous hemangioma which was an 8 on a scale of 1 to 10, and did not have full movement of the leg. Indeed, the evidence includes the veteran's subjective complaints of experiencing pain at all times in the left knee (see September 1998 addendum opinion), and the examiner's opinion in 1998 that the veteran's basic problem was a subjective one of pain. Thus, while the record does not clearly indicate the extent of any additional functional loss due to pain, the Board finds that, with resolution of all reasonable doubt in the veteran's favor, the veteran's cavernous hemangioma of the left leg results in overall functional loss due to pain comparable to his present compensable (10 percent) rating. This is especially so in view of the examiner's observance at the July 1998 examination that the veteran tended to not want to fully extend the knee despite the fact that he could (thus indicating discomfort in doing so), and the fact that the veteran was subsequently unable to fully extend the knee at a VA examination in April 1999. The Board thus concludes that the evidence is most consistent with the veteran's present compensable (10 percent) rating under Code 5261 for functional loss due to pain. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. at 204-7. A higher than 10 percent rating is not warranted under Code 5261 when considering that strict adherence to the limitation of extension criteria does not approximate more than a noncompensable rating. As the preponderance of the evidence is against the veteran's claim for a rating greater than 10 percent for cavernous hemangioma of the left popliteal area, the benefit of the doubt doctrine is not applicable, and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER The claim for a compensable rating for hemorrhoids is denied. The claim for a rating greater than 10 percent for bilateral pes planus is denied. The claim for a rating greater than 10 percent for cavernous hemangioma of the left popliteal area is denied. C.W. Symanski Member, Board of Veterans' Appeals