BVA9503015 DOCKET NO. 91-50 194 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for a bilateral ankle disability. 2. Entitlement to an increased rating for bilateral pes planus, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD William W. Berg, Counsel INTRODUCTION The veteran had active military service from September 1962 to September 1966. When this case was previously before the Board of Veterans' Appeals (Board) in April 1993, it was remanded to the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee, for additional development. The case is now before the Board for final appellate consideration. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends, in essence, that he has a bilateral ankle disability as a result of his service-connected bilateral pes planus. It is maintained that the veteran's pes planus with pronation syndrome causes chronic lateral ankle instability. He maintains that the recent medical evidence has made no mention of his recurrent ankle sprains, which he claims are a manifestation of an unstable ankle. He claims that he has ligamentous damage around the ankles and X-ray evidence of an old injury to the left ankle. He argues that VA has recommended that he wear RICE ankle supports but simultaneously denies his claim on the basis that permanent disability of the ankles is not shown. He contends that he had been employed as a service technician with full benefits for many years and that he had substantial problems with his ankles and feet. He claims that now that he runs his own business, however, he can stay off his feet more and thus has fewer sprains and other ankle problems. He challenges the adequacy of recent VA examinations and states that he was examined by physicians in the same clinic. He claims that these doctors would not contradict one another. Finally, it is contended that he is entitled to a disability evaluation in excess of 10 percent for his bilateral pes planus. He maintains that pain and other symptoms associated with his bilateral pes planus have increased and thus warrant increased compensation. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence is against the claim for service connection for a bilateral ankle disability; it is the further decision of the Board that the preponderance of the evidence is against a disability evaluation in excess of 10 percent for bilateral pes planus. FINDINGS OF FACT 1. All evidence necessary for an equitable disposition of this appeal has been obtained. 2. It is not shown that a chronic bilateral ankle disability was present in service or that the veteran has a separate chronic bilateral ankle disability currently. 3. The service-connected bilateral pes planus is productive of no more than moderate disability. 4. No unusual or exceptional disability factors have been presented with respect to the veteran's service-connected bilateral pes planus. CONCLUSIONS OF LAW 1. A bilateral ankle disability was not incurred in or aggravated by service, nor does the veteran have a bilateral ankle disability that is due to or the proximate result of service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 1991); 38 C.F.R. §§ 3.303, 3.310(a) (1993). 2. The criteria for a disability evaluation in excess of 10 percent for bilateral pes planus have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321(b)(1), 4.7, 4.71a, Code 5276 (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS As a preliminary matter, the Board finds that the veteran's claims are plausible and thus well grounded within the meaning of 38 U.S.C.A. § 5107(a). The Board is also satisfied that all relevant evidence has been obtained with respect to these claims and that no further assistance to the veteran is required in order to comply with the duty to assist mandated by statute. In so finding, the Board has considered the veteran's contention that recent examinations have been inadequate. The Board has reviewed the recent medical evidence and is satisfied that there is sufficient evidence to adjudicate these claims. The recent examinations contain complaints, history, clinical findings, X- ray studies, diagnoses and comments on the evidence fully adequate for an equitable consideration of this appeal. The Board observes that the fee-basis examinations in 1992 and 1993 were by orthopedic surgeons, albeit from the same private clinic. However, there is no evidence whatsoever that the opinions of these physicians were predicated on their professional association rather than on their clinical findings. The veteran's assertion that physicians in the same clinic would not contradict each other does not constitute evidence that the examiners colluded, or even deferred to each other, in arriving at their findings in this case. In the absence of evidence, the Board rejects the implication that their examinations are compromised by their professional association. I. Service Connection for a Bilateral Ankle Disability Although the veteran contends that he has a bilateral ankle disability as a result of service, there is no evidence to support this claim. The service medical records reveal that, beginning in June 1964, the veteran was seen on a number of occasions at a service orthopedic clinic for complaints related to his feet. He expressed concern about his feet when examined for separation in September 1966, and he was referred for orthopedic evaluation, which found that both of his arches rolled down over the medial aspect when he walked. It was reported that he did not seem to have any support in his shoes, and it was indicated that he had been informed that arch supports would alleviate his complaints. An examination was otherwise negative for any pertinent pathology. When examined by VA in 1971, ankle and subtalar motion was normal, although a slightly tight heel cord was noted bilaterally. Private medical reports by Drs. Rutan and Hellman do not establish that the veteran has a chronic bilateral ankle disability. The veteran was seen in March 1990 for complaints of discomfort in the knees. His complaints resulted in visits to a VA orthopedic clinic, where two small bony avulsions from an old injury in the left ankle were noted. It was reported that there was ligamentous instability in the left ankle. An October 1990 addendum to an the August 1990 outpatient note recommended bilateral RICE ankle supports to prevent acceleration of ligamentous damage around the ankles with accompanying pain. The evidence does not show, however, that the bony avulsions noted in 1990 are due to a left ankle injury that was sustained in service or are the proximate result of a service-connected disability. They have not been attributed to service by examining physicians. Any left ankle instability resulting from an injury that is not shown to be related to service does not provide a basis for service connection. On VA examination in July 1992, a history of multiple ankle sprains was noted, but the veteran was found to have stable ankles on clinical examination, and no significant abnormalities were visualized on X-rays of the ankles. Significantly, no calcifications or indications of chronic severe sprains were noted. The examiner commented that the veteran might well have had multiple minor sprains but that it did not appear that there had been anything severe that had left him with chronic problems. When the veteran was examined for VA in August 1993, the examiner found easy ankle motion without specific point tenderness in the ankles. In an addendum dated the following January, the VA examiner found no permanent impairment of the ankles. He was of the opinion that the only rationale for including the ankle with the disability evaluation was that the ankle might be symptomatic because of the pronation of the midfoot and stresses on the medial side of the arch. The examiner thus indicated that the veteran did not manifest a chronic ankle disability as a distinct and separate disability. Rather, the examiners appear to be of the opinion that the ankle symptoms are actually manifestations of the service-connected bilateral pes planus. Dr. Rutan in November 1978 reported that the veteran had what he described as a talonavicular cuneiform fault bilaterally, and he reported that the veteran clinically manifested limitation of dorsiflexion of the ankle joint on flexion and extension of the knee. In a letter dated in August 1979, Dr. Rutan attributed the bilateral talonavicular cuneiform fault to the veteran's "compensated rear foot varus bilaterally." However, Dr. Rutan went on to state that appropriate orthotics would alleviate the veteran's symptoms. When seen in January 1980, the veteran was reported to be "doing fine" with the orthotics recommended by Dr. Rutan. A November 1990 assessment by a VA podiatry clinic was to the effect that the veteran has chronic lateral ankle instability secondary to pes planus with pronation syndrome, but the recent examinations for VA have not confirmed the presence of a separate chronic bilateral ankle disability. Although the veteran maintains that it is inconsistent for VA to prescribe ankle supports while denying the presence of a chronic ankle disability, this treatment is consistent with an attempt by VA to retard the pain and ligamentous wear and tear resulting from pronation of the midfoot and stresses on the medial side of the arch due to the service-connected bilateral pes planus. The Board notes that when the veteran was examined by Dr. Rutan in August 1993, he was found to exhibit a relatively normal amount of inversion and eversion of the ankle. The Board finds that in the absence of a chronic bilateral ankle disability attributable to service separate from the service-connected bilateral pes planus, service connection for a bilateral ankle disability is not warranted on either a direct or secondary basis. 38 U.S.C.A. § 1110, 1131; 38 C.F.R. § 3.310(a); see Brammer v. Derwinski, 3 Vet.App. 223, 225 (1992). In so finding, the Board has considered the evidence of Drs. Rutan and Hellman, as well as the statements and testimony of the veteran, but this evidence does not warrant service connection for the claimed bilateral ankle disability. The veteran is undoubtedly sincere in testifying that he has a chronic bilateral ankle disability as a result of service-connected disability. A claimant is competent to testify, however, only with respect to the symptoms he experiences; he is not competent to render a medical opinion showing the existence of a chronic bilateral ankle disability or attributing that disability to his service- connected bilateral pes planus. See Grottveit v. Brown, 5 Vet.App. 91, 92-93 (1993); Espiritu v. Derwinski, 2 Vet.App. 492, 494-95 (1992). The Board therefore concludes that the preponderance of the evidence is against the claim for service connection for a chronic bilateral ankle disability. II. Increased Evaluation for Bilateral Pes Planus Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities (rating schedule) found in 38 C.F.R. Part 4 (1993). The Board attempts to determine the extent to which the veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. §§ 4.1, 4.10 (1993). In accordance with 38 C.F.R. §§ 4.1, 4.2 (1993), and Schafrath v. Derwinski, 1 Vet.App. 589 (1991), the Board has reviewed the service medical records and all other evidence of record pertaining to the history of the service-connected bilateral foot disability. The Board has found nothing in the historical record that would lead to the conclusion that the current evidence of record is not adequate for rating purposes. The Board is of the opinion that this case presents no evidentiary considerations that would warrant an exposition of the remote clinical histories and findings pertaining to the disability at issue. See Francisco v. Brown, 7 Vet.App. 55, 58 (1994). The RO has rated the veteran's service-connected bilateral pes planus as moderately disabling and has assigned a 10 percent evaluation, which has been in effect since March 1971. Under the rating schedule, moderate symptoms with the weight-bearing line over or medial to the great toe, inward bowing of the tendo achillis, pain on manipulation and use of the feet warrant a 10 percent evaluation; a 30 percent evaluation is warranted for severe bilateral acquired pes planus manifested by marked deformity (such as pronation or abduction), accentuated pain on manipulation and use of the feet, indications of swelling on use of the feet, and characteristic callosities. 38 C.F.R. § 4.71a, Code 5276. When seen on VA orthopedic consultation in 1990, it was reported that the veteran's pes planus was not prominent. However, when seen at a VA orthopedic clinic in March 1991, his pes planus was described as moderately severe, although his feet were said to exhibit only "slight pronation." On examination for VA in July 1992, his pes planus was again described as moderately severe. However, it was observed that although he had little arch left when he stood on his toes, he reconstructed the arch fairly nicely. His heels appeared to be in about the appropriate amount of valgus without severe hindfoot deformity. He walked without any problem and without a limp. His pulses were good, and his neurovascular status appeared normal. The musculature was well developed. The ankles appeared stable. X-rays of the feet showed "pes pedis," while bony mineralization and joint space were normal. The diagnoses were flexible pes planus, bilaterally, and history of recurrent ankle sprains. On examination for VA in August 1993, the veteran exhibited easy hindfoot motion, easy ankle motion, and easy midfoot motion without specific point tenderness in the feet and ankles. He had excellent orthotics with good cushions. Recent and old X-rays were reviewed, but the examiner found nothing and felt that they were normal. It was reported that the veteran took ibuprofen occasionally, and he was advised to take it when he was symptomatic rather than just occasionally. The examiner remarked that the veteran had been treated with orthotics from VA and by a private podiatrist and that he had done quite well. The examiner was of the opinion that the veteran had minimal problems. The examiner reported the veteran complained that he was a little stiffer than he used to be and that, when he was on his feet full time, his feet sometimes ached a little. The veteran reportedly indicated that he just wanted to be sure that there was not something else that was going wrong at the site of his service- connected problem. The examiner suggested that he continue with the same treatment and remarked that he would not change the veteran's evaluation of impairment after the day's visit. In an addendum dated the following January, the examiner reiterated that the veteran was able to function well with the orthotic that he wore in his shoe. The Board notes that testimony at the RO in May 1991 indicated that the veteran wore molded plastic devices that fit inside his shoes from the heel to the midsole. The veteran testified that he never went without these shoe supports because they offered some support. He further testified that he had been issued ankle supports by VA. He testified that he had pain and some swelling near the arch of his forefoot when he was ambulatory. He also said that he did not have a lot of calluses because he did not stay on his feet except when he was working. The recent examination findings shows that the veteran's current symptoms of bilateral pes planus are no more than moderate in degree and do not more nearly approximate the symptomatology required for the next higher evaluation. 38 C.F.R. § 4.7. Marked deformity such as pronation or abduction, accentuated pain on manipulation and use of the feet, indications of swelling on use of the feet, and characteristic callosities were not shown when the veteran was recently examined. Although the pes planus had earlier been characterized as moderately severe, the recent clinical findings have not supported this characterization, nor have the more recent findings supported the veteran's earlier testimony. In evaluating a service-connected disability, the Board attempts to determine the extent to which a service-connected disorder adversely affects the ability of the body to function under the ordinary conditions of life, including employment. 38 C.F.R. § 4.10. The Board also considers functional loss due to damage or pain. Functional loss contemplates the inability to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance, and it must be manifested by adequate evidence of disabling pathology, especially when functional loss is due to pain. 38 C.F.R. § 4.40. Although the veteran continues to complain of pain in his ankles, the examiner in January 1994 associated the ankle pain with the service-connected bilateral pes planus. Pain is contemplated in the 10 percent evaluation currently assigned, and a basis for an increased evaluation cannot be identified in the absence of evidence of functional impairment due to pain. Here, the bilateral foot disability is adequately remedied by the use of appropriate orthotic devices. The evidence with respect to the service-connected pes planus, moreover, does not present such an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards and thus warrant assignment of an extraschedular evaluation under 38 C.F.R. § 3.321(b)(1). The veteran has not required frequent periods of hospitalization for his service-connected disability, nor does the evidence show that the disability has resulted in marked interference with employment. The veteran has contended in statements and testimony of record that his bilateral pes planus adversely affected his ability to perform his job as a heating, air conditioning and appliance technician. The veteran also has indicated that he now runs his own business, which allows him to stay off his feet more. However, the evidence on this point indicates that while he no doubt experienced considerable discomfort in his work as a service technician as a result of his pes planus, that disability, by itself, is not so disabling as to require extra-schedular consideration. The Board is of the opinion that the clinical findings on the examinations for VA in 1992 and 1993 simply do not support the assertion that the service-connected disorder was so severe as to produce the marked interference with employment contemplated by 38 C.F.R. § 3.321(b)(1) in order for an extraschedular evaluation to be warranted. The Board therefore concludes that the preponderance of the evidence is against the claim for an evaluation in excess of 10 percent for service-connected bilateral pes planus. ORDER Service connection for a bilateral ankle disability is denied. An increased evaluation for bilateral pes planus is denied. ROBERT E. SULLIVAN Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.