BVA9506477 DOCKET NO. 93-10 777 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for a right upper arm disorder. 2. Entitlement to an increased evaluation for calluses and bunions with fungus infection of the right foot, currently evaluated as 10 percent disabling. 3. Entitlement to an increased evaluation for calluses and bunions with fungus infection of the left foot, currently evaluated as 10 percent disabling. 4. Entitlement to an increased evaluation for bilateral tinea manus, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Alice A. Booher, Counsel INTRODUCTION The veteran had active service from June 1973 to June 1976, and from August 1977 to July 1981. Service connection was denied by the Board of Veterans' Appeals (the Board) in March 1983 for "aggravation for scar, plantar surface, left foot." A 10 percent rating was assigned for his bilateral tinea manus by the Board in April 1991. This appeal is from a rating action by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia in July 1992. The veteran provided testimony before a member of the Board at a personal hearing held at the RO in July 1993; a transcript is of record. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that he now has a right upper arm disorder related to intra-muscular inoculations administered during service, that his service medical records clearly document right upper arm complaints on July 31 and August 8, 1973, and that the VA was obliged to obtain a medical opinion as to whether any current upper right arm disorder is related to the "process" noted in service. It is contended that his skin condition has worsened and warrants increased ratings, including separate ratings for each hand. 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 veteran's claim for service connection for a right arm disorder is not well grounded, and that the preponderance of the evidence is against increased evaluations for his calluses and bunions with fungus infection of the right and left feet and for bilateral tinea manus. FINDINGS OF FACT 1. Adequate evidence for an equitable disposition of the issues on appeal is of record. 2. The veteran is not shown to have had any lump or numbness of the right upper extremity during service or for many years thereafter. 3. There is no medical evidence or opinion that current complaints of a lump or cyst on the right arm, or of numbness and tingling in the right arm, are the result of any incident of service including inoculations. 4. The veteran's bilateral foot disability is manifested by mild scaling of the soles with mild maceration in the toe webs, a few keratotic papules on the soles, and callosities on the metatarsal areas of both feet without deformities, edema or contractures, and without bunions on X-ray or clinical evaluation. Disability of each foot is of no more than moderate degree. 5. The veteran's tinea manus of both hands is manifested by mild scaliness; lesions are on an exposed surface but are not extensive; there is no constant itching or exudation; and the skin disorder does not cause marked disfigurement or significant functional impairment. 5. The current manifestations of the veteran's hand and foot disorders do not more nearly approximate the criteria for higher evaluations and do not present an unusual disability picture with related factors such as marked interference with employment or the need for frequent periods of hospitalization. CONCLUSIONS OF LAW 1. The veteran's claim for service connection for a right arm disorder is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 2. The criteria for an increased evaluation for calluses and bunions with fungus infection of the right foot, currently evaluated as 10 percent disabling, are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. § 3.321(b)(1), Part 4, §§ 4.7, 4.20, Diagnostic Code 7819-5284 (1994). 3. The criteria for an increased evaluation for calluses and bunions with fungus infection of the left foot, currently evaluated as 10 percent disabling, are not met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. § 3.321(b)(1), Part 4, §§ 4.7, 4.20, Diagnostic Code 7819-5284. 4. The criteria for an increased evaluation for bilateral tinea manus, currently evaluated as 10 percent disabling, are not met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. § 3.321(b)(1), Part 4, §§ 4.7, 4.20, Diagnostic Code 7899-7806 (1994). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Well-grounded Claims Pursuant to 38 U.S.C.A. § 5107(a), a person who submits a claim for benefits under a law administered by the Secretary shall have the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded. The United States Court of Veterans Appeals (Court) has held that a well-grounded claim is "a plausible claim, one which is meritorious on its own or capable of substantiation." Murphy v. Derwinski, 1 Vet.App. 78, 81 (1990). In Boeck v. Brown, 6 Vet.App. 14 (1993), the Court held that A(n appellant) claiming entitlement to VA benefits has the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded. See 38 U.S.C.A. § 5107, and see Tirpak v. Derwinski, 2 Vet. App. 609, 610-11(1992). If a claim is not well grounded, the Board does not have jurisdiction to adjudicate that claim. See Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Service Connection The veteran's service medical records show that in July 1973, he complained of an intermittent burning type pain in his right shoulder, described as "pins and needles," which had commenced while he was on the rifle range. On examination, he reported vague pain in the right upper trapezius after heavy lifting. There was no evidence of a "lump" noted, and range of motion and strength were normal. The diagnosis was mild upper trapezius (muscle) strain, and he was told to apply heat locally at home. On August 8, 1973, he was seen for a complaint of coughing up blood. When he was examined in April 1976 for separation from his first period of service, there was no finding of any right upper extremity or shoulder abnormality. Service medical records further reflect that in June 1978, the veteran complained of pain in the left shoulder which was felt to be due to muscle strain. In December 1979, he complained of an upset stomach and malaise after getting a flu shot, and reported right thumb pain. He was given aspirin and returned to duty. The veteran's original immunization record shows that he received a number of routine inoculations. Service medical records reflect no complaints or clinical findings of any lump in the right shoulder or deltoid area, including on the separation examination in June 1981, when the upper extremities were found to be normal. After service, the veteran's initial claim for benefits in 1981 made no reference to a right arm disorder. In 1982, he reported pain in the right arm and wrist. Medical evidence was received relating to his having broken his right radius in 1970, prior to entry into service. VA examination reports of 1981, 1984 and 1986, and private and VA outpatient clinical reports, dating from separation from service until 1992, reflect no complaints or clinical findings of any right arm lump. The veteran filed a claim for right upper arm disability in 1992. Evidence submitted in conjunction with his claim shows that he was seen as a VA outpatient in March 1992 with complaints of a tingling and numbness in his right arm. The veteran reportedly had developed a lump on his right arm which he claimed was painful at times, and which he felt was a result of inoculations in service. On examination, a "cyst" was noted be secondary to a shot given in the military. He also complained of pain in both upper extremities which was felt to possibly be bursitis or tendinitis. Several days later in March 1992, he was seen at the Medical College of Virginia with complaints of a lump on his right arm which had enlarged over a period of years. He said it had started as a small bump over 10 years ago when he received multiple injections in the military. The impression was possible epidermal cyst versus lipoma. The examiner reported that he had told the veteran that a definite diagnosis could not be made without a tissue sample and recommended a needle aspirate, biopsy or excision, options which the veteran said he would consider. On examination, a moderately firm, subcutaneous nodule was located at the inferior border of the deltoid of the right arm which was mobile, nontender and well defined. At a July 1993 hearing before a Board Member, the veteran testified that he started experiencing problems with his right arm when he got inoculations, and was told that the bumps in that area were common. He felt that the problems of numbness were a result of the shots. Transcript (Tr.) at 3. The veteran reported that he had not sought treatment for the itching and small white bumps. Tr. at 4. He further clarified that the fatty lump he has now was not the way it first grew, but that it was on the same spot. Tr. at 5. He reported having had a pins and needles sensation, numbness and pain as a result. Tr. at 6- 7. When asked about its development, the veteran reported that he had been told that a definite diagnosis could not be done without biopsy, etc., but that he had been told by one physician that the lump looked as if it was growing. Tr. at 9. In regard to the claim for service connection, the law and regulations provide that service connection may be granted for disability resulting from disease or injury incurred in or aggravated during active duty. 38 U.S.C.A. § 1110, 1131 (West 1991). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (1994). Although in July 1973, shortly after service entrance, the veteran complained of right shoulder pain and a "pins and needles" sensation, no upper arm lump or other objective abnormality was noted. He was thought to have a mild upper trapezius strain. While he contends that he was also seen on August 8, 1973, for pertinent complaints, he was seen on that date for a complaint of coughing up blood. There were no right arm or shoulder complaints or abnormal findings noted in subsequent service medial records and his upper extremities were found to be normal on examination for final discharge from service in June 1981. It is not until a decade after service that there is medical evidence of a right upper arm lump. Although reports from the VA and a private physician can be construed as indicating that he had the lump since being given a shot in service, these remarks are clearly based on a recitation by the veteran of his "history." This history is not confirmed by medial records which, in fact, show that the right upper arm was normal at service discharge in 1981. Only the veteran has associated current right arm numbness and tingling and a cyst or "lump" in the right deltoid area with service, and any suggestion by physicians in that regard as noted above, was made based on history given by the veteran. While he testified that he believes his in-service inoculations have resulted in his current problems, he is not trained in medicine, and as a lay person, is not qualified to determine medical causation. See Espiritu v. Derwinski, 2 Vet.App. 492 (1992). Inasmuch as there is no medical evidence or opinion linking any current right upper arm disorder with any events of service, the claim for service connection for a right upper arm disorder is not well grounded. 38 U.S.C.A. § 5107(a). Increased Evaluations In claims for increased disability ratings, the Court of Veterans Appeals (the Court) has found that, within the confines of certain parameters, the allegation by a veteran that he has increased disability tends to establish a well-grounded claim. Proscelle v. Derwinski, 2 Vet.App. 629 (1992). In general, disability evaluations are determined by the application of a schedule of earnings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. When an unlisted condition is encountered, it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. Conjectural analogies will be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings. Nor will ratings assigned to organic diseases and injuries be assigned by analogy to conditions of functional origins. 38 C.F.R. § 4.20. When there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Where the minimum schedular evaluation requires residuals and the schedule does not provide for a zero percent evaluation, a zero percent evaluation will be assigned when the required residuals are not shown. 38 C.F.R. § 4.31. In exceptional cases where the schedular evaluations are found to be inadequate, an extraschedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability may be approved provided the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321 (b)(1). The Board has also considered all of the facets of the disorder including alternative provisions that may be applicable pursuant to Schafrath v. Derwinski, 1 Vet.App. 589 (1991). The Schedule for Rating Disabilities provides that benign new growths of the skin are ratable as scars, disfigurement, etc. 38 C.F.R. Part 4, Diagnostic Code 7819. Superficial scars that are poorly nourished with repeated ulceration; or which are tender and painful on objective demonstration are ratable as 10 percent disabling. 38 C.F.R. Part 4, Diagnostic Codes 7803, 7804. Disfiguring scars of the head, face and neck are rated under Diagnostic Code 7800 primarily based on the degree of disfigurement. Other scars are ratable on limitation of function of the part affected under Diagnostic Code 7805. Certain skin disorders, including dermatophytosis (fungus infections), are ratable as for eczema, dependent upon the location, extent and repugnance or otherwise disabling characteristics or manifestations. 38 C.F.R. Part 4, Diagnostic Code 7813. Eczema is ratable as zero percent disabling with slight, if any, exfoliation, exudation or itching, if on a nonexposed surface or small area. A 10 percent rating is assignable with exfoliation, exudation or itching, if involving an exposed surface or extensive area. A 30 percent rating is assignable with exudation or itching constant, extensive lesions or marked disfigurement. A 50 percent rating is assignable with ulceration or extensive exfoliation or crusting, and systemic or nervous manifestations, or exceptionally repugnant. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4, Diagnostic Code 7806. Calluses and bunions are ratable by comparison to other foot injuries, with the assignment of a 10 percent rating for moderate, 20 percent for moderately severe, or 30 percent for severe impairment. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4, Diagnostic Code 5284. Another possible alternative provision might be as metatarsalgia (Morton's disease), whether unilateral or bilateral, when a 10 percent rating is assignable. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4, Code 5279. VA outpatient records confirm that the veteran is periodically seen for his skin problems; medications are refilled, and the areas are debrided, etc., as warranted. During the mid to late 1980's he was seen on numerous occasions at the podiatry and dermatology clinics. In July 1987, he was noted to have cracking and scaling of the skin on the plantar aspect of his feet and plantar lesions. When he was given a VA dermatology examination in December 1987, scaling of the palms and feet was noted. There were no fissures. The diagnostic impressions were miniscule amount of tinea pedis, and tinea manus. A podiatry examination at that time revealed plantar tyloma and keratosis. When the veteran was seen at a VA outpatient clinic in March 1992, he was noted to have a history of hyperkeratoses of the feet and mild fungus infection. He complained of itching. He was referred for podiatry and dermatology consultations. On a VA examination in May 1992, the veteran reported that he had been treated over the years with Miconazole Cream and Zeasorb Powder with fair results. On examination, there was mild scaling of the palms and soles with mild maceration in the toe webs. In addition to the (nonservice-connected) linear scar of approximately 3 centimeters present on the left sole, there were a few keratotic papules present on the soles. Testing was negative for hyphae from the toe webs. Color photographs accompany the examination report and are consistent therewith. The diagnoses were tinea pedis and tinea manum, currently under treatment. On a separate examination of his feet, there were callosities on the metatarsal areas of both feet, without deformities or contractures. Arches were well developed. There was no edema. X-rays of both feet were normal; and no bunions were seen on X-ray or clinical evaluation. The diagnosis was moderate degree callosity, metatarsals both feet. At his hearing, the veteran testified that he continues to have problems with both his feet and hands. However, although he testified that he was receiving VA treatment on a regular basis, he could not recall when he was last seen, indicating that it was within the last year. Tr. at 29. He also testified that his hand disorder is manifested by redness, scaling, itching and numbness, and that he should receive at least a 10 percent rating for each hand. He testified that he loses 5-10 days per month at a minimum because of his disabilities, and argued that the most recent VA examination was inadequate. In regard to the veteran's claim that the most recent VA examination was inadequate, the Board does not concur. He was examined by two physicians, their findings are described in the examination reports, and photographs and X-rays of his feet were taken. The examination report, along with the other evidence of record, provides an adequate basis for assessing the disabilities at issue. In regard to the veteran's hands, clinical findings at present are limited primarily to scaliness. While the hand involvement is on an exposed surface, the overall impairment is no more than minimal, and does not more nearly approximate the criteria required for an evaluation in excess of 10 percent. Only mild scaling was noted on the most recent VA examination, and reportedly the veteran had no subjective complaints. In this regard, the Board has taken into account the aggregate disability. Although the veteran has argued that he should be given a compensable rating for each of his hands, there is no schedular requirement that individual ratings be assigned for disparate parts of the body, in this case both hands. Absent evidence of constant itching or exudation, extensive lesions or marked disfigurement, an evaluation in excess of 10 percent for the veteran's tinea manum is not warranted. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. Part 4, Code 7899-7806. In regard to the veteran's feet, originally one rating was assigned for both feet. However, it was later shown that he had significant pathology of each foot, including corns, tyloma, and keratoses, and by a 1984 rating decision he was given separate ratings for each foot. There is no current X-ray evidence of bunions or other foot deformity. The most recent examination showed mild scaling of the soles of the feet with mild maceration in the toe webs. There were also a few keratotic papules on the soles and metatarsal callosities. As noted above, Diagnostic Code 7806, requires constant itching or exudation, extensive lesions or marked disfigurement for a 30 percent rating. This level of disability is clearly is not shown. Under Diagnostic Code 5284, there would have to be moderately severe foot disability to warrant a 20 percent rating. The skin findings in this case are not the equivalent of moderately severe impairment of each foot and are encompassed by the currently assigned 10 percent rating for each foot. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.20, Diagnostic Code 7819-5284. The veteran testified that he misses "5-10 days per month" because of his disabilities. He was unclear about what it is that he misses. However, there is no collateral evidence to indicate that the veteran, who is primarily a student, has foot or hand disabilities that present an unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as required for an extraschedular evaluation under 38 C.F.R. § 3.321(b)(1). ORDER The veteran's claim for service connection for a right upper arm disorder is dismissed. Increased evaluations for calluses and bunions with fungus infection of the right foot, for calluses and bunions with fungus infection of the left foot, and for bilateral tinea manus, are denied. JANE E. SHARP 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.