BVA9500590 DOCKET NO. 93-10 476 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Hartford, Connecticut THE ISSUE Entitlement to an increased evaluation for service-connected chronic lymphedema of the left lower extremity, with history of recurrent cellulitis, currently rated as 10 percent disabling. WITNESSES AT HEARING ON APPEAL The veteran and his wife ATTORNEY FOR THE BOARD Bernard T. DoMinh, Associate Counsel INTRODUCTION The veteran served on active duty from November 1987 to December 1991. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an April 1992 rating decision by the Hartford, Connecticut, Regional Office (RO) of the Department of Veterans Affairs (VA), which granted service connection for chronic lymphedema of the left lower extremity, and assigned a rating of 10 percent. The file indicates that the veteran is also claiming service connection for athlete's foot. As this issue has not yet been adjudicated, it is referred to the RO for additional development and consideration. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that the symptoms of his service-connected chronic lymphedema of his lower left extremity warrant a 30 percent disability rating, based on definite swelling after being on his feet for one or two hours, and the requirement that he wear a Jobst stocking for the rest of his life. 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 veteran's claim for an increased rating for service-connected chronic lymphedema of the left lower extremity, currently rated as 10 percent disabling. FINDINGS OF FACT The veteran's chronic lymphedema of the left lower extremity (with history of cellulitis) is manifested by variable edema of the left foot, ankle and lower leg up to the knee, ranging from trace swelling of the ankle in the morning to definite swelling at the end of the day, necessitating the use of a Jobst stocking, and aching and swelling after prolonged standing. CONCLUSION OF LAW The criteria for a rating in excess of 10 percent for chronic lymphedema of the left lower extremity have not been met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. §§ 3.321, 4.7, Part 4, Code 7199-7121 (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Factual Background The veteran's service medical records show that he developed suppurative lymphadenitis in his left groin and underwent a superficial lymphadenectomy in August 1989. While still in service, he subsequently had three episodes of significant cellulitis of his left lower extremity, including cellulitis which was secondary to athlete's foot. Treatment during these episodes involved hospitalization and administration of intravenous antibiotics. Thereafter, he developed persistent lymphedema of the left lower extremity. The veteran received treatment during service for lymphedema at private and military medical facilities, including the Lawrence and Memorial Hospital (a private hospital). A unilateral lymphangiogram performed at this facility revealed signifi-cant interruption of the normal anatomy of the lymphatic system in his left leg and the diagnosis of lymphedema was confirmed. Elastic support stockings were recommended for his condition. In August 1991, a Physical Evaluation Board (PEB) made the determination that the veteran was unfit for further active duty because of his diagnosed recurrent cellulitis and chronic lymphedema of the left lower extremity. The PEB concluded that a disability discharge with severance pay and assignment of a 10 percent disability rating was warranted. In the course of the PEB proceedings, the veteran had unsuccessfully challenged the 10 percent disability rating, contending that his condition warranted a higher evaluation. The veteran was separated from service in December 1991. In an April 1992 decision, the RO granted the veteran service connection for chronic lymphedema of the left lower extremity, with a history of recurrent cellulitis, and, in concurrence with the evaluation of the PEB, assigned a 10 percent disability rating. In an October 1992 statement, Scheuster E. Christie, M.D., reported that, in April 1992, the veteran was admitted to St. Francis Hospital in an emergent condition with severe left lower extremity edema, cellulitis and lymphangitis. While in the hospital, he was treated with intravenous antibiotics, leg elevation and compression stockings. Venous dopplers were obtained along with vascular surgical consulta-tion. He recovered and was discharged from the hospital after approximately six days. Dr. Christie's diagnosis of the veteran's condition was post-infection lymphatic obstruction of the left lower extremity. The physician's plan of treatment involved aggressive antibiotic treatment for any lower extremity infection that might occur. He also instructed the veteran to elevate his legs as much as possible, avoid standing for more than one hour at a time, wear a knee-high Jobst stocking on his left leg whenever he was out of bed, and use a Jobst compression pump for 2 to 3 hours every evening at home. Dr. Christie informed the veteran that failure to comply with his instructions could lead to persistent lower extremity edema, possible lower extremity ulceration, recurrent cellulitis, possible bacteremia and sepsis, and treatment by amputation of the affected extremity. During an RO hearing in October 1992, the veteran testified that he worked a desk job and that he had to maintain his left leg in an elevated position as often as possible during work because of his condition. He would experience aches in his left leg which would occur after 30 minutes to several hours of standing. He had to wear a special elastic support stocking (Jobst stocking) and use a Jobst compression pump daily to control edema in his left leg. He stated that his leg would swell frequently, even while wearing the stocking, causing him to limp. He also said the stocking was uncomfortable to wear, and that despite the stocking, he could observe visible swelling of his left leg at the end of his workday. He reported that his physician informed him that infections were prone to settle in his left leg because of poor circulation in the area caused by his disability. His wife testified that when he was hospitalized for the episode of post-infection lymphatic obstruction of the left lower extremity in April 1992, he had marked swelling of his left leg and difficulty remaining conscious. The veteran reported that he had lost time from work because of his hospitalization in April 1992 (for approximately 6 days) and the subsequent follow-up medical visits, and sometimes he had to leave work early because of the symptoms of his condition. He also reported that in April 1990 he was treated for athlete's foot at Jacksonville Naval Hospital, which caused an infection in his left leg affecting the area from the knee downward. Since then, he had had no recurrence of athlete's foot for the remainder of his active service or since his separation from service. During a December 1992 VA examination, the veteran complained of aching and swelling of his left leg when standing for extended periods of time. He reported that he wore a Jobst stocking daily to control edema of his left leg. He also reported that his last incident of athlete's foot was in November-December 1990, that he used anti-fungal foot powder daily, and that he changed his shoes daily to avoid exposing his skin to moisture and infection. Physical examination (at 9:00 a.m.) revealed a 2 1/2-inch linear scar on his left groin with no deformity, trace swelling of his left ankle, a 1-inch scar on the top of his left foot, status post a lymphogram at Lawrence and Memorial Hospital, and a small 1-centimeter node in his left groin. He had good pedal pulses, skin temperature in both of his feet was cool to the touch, and he had no paresthesias. There was trace edema of his left foot. The lymphe-dema secondary to recurrent cellulitis was not apparent in the morning, but the veteran reported that at the end of the day his ankle, foot and leg (up to the knee) would be edematous. ("Can see creases in skin from stocking.") The only area affected by the disorder was the left lower extremity from the knee down. The diagnoses were history of recurrent cellulitis, left lower leg (4 episodes); status post excision of lymph node, left groin; status post lymphogram in March 1991; recurrent epidermophytosis, left foot; and recurrent cellulitis and lymphedema of the left lower extremity. II. Analysis The veteran's claim is well-grounded within the meaning of 38 U.S.C.A. § 5107(a), in that it is not inherently implausible. Relevant evidence has been properly developed, and no further assistance to the veteran is required to comply with the duty to assist. Id. Disability evaluations are determined by the application of a schedule of ratings 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 in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. In this case, the veteran's chronic lymphedema of left lower extremity has been rated as analogous to unilateral phlebitis or thrombophlebitis. A 10 percent evaluation is warranted for unilateral phlebitis or thrombophlebitis with obliteration of deep return circulation, including traumatic conditions, with persistent moderate swelling of a leg which is not markedly increased on standing or walking. A 30 percent evaluation requires persistent swelling of a leg or thigh which is increased on standing or walking 1 or 2 hours, but is readily relieved by recumbency; with moderate discoloration, pigmentation or cyanosis. 38 C.F.R. Part 4, Code 7121. The evidence indicates that the veteran's service-connected disorder, diagnosed in the December 1992 VA physical examination as recurrent cellulitis and lymphe-dema of the left lower extremity, is manifested by trace swelling of the left ankle in the morning, ranging to definite swelling of the foot, ankle, and lower leg at the end of the day, with aching and swelling after prolonged standing. Though there appears to be increased swelling on standing, it does not appear from the evidence that this symptom is markedly increased over the usual edematous swelling which occurs daily. Additionally, there is no showing of any discoloration, pigmentation or cyanosis of the affected area. Therefore, the Board finds that an increased evaluation to 30 percent is not warranted because the symptoms of the veteran's condition more closely approximate the criteria for a 10 percent disability rating. 38 C.F.R. § 4.7. Because the evidence is not approximately balanced, the reasonable doubt doctrine does not apply. 38 C.F.R. § 4.3. The provisions of 38 C.F.R. § 3.321, which pertain to extraschedular ratings, have been considered. However, as the evidence shows that the veteran has been hospitalized for his condition only once since leaving service, and that his condition does not markedly impair his industrial capacity, an increased rating on an extraschedular basis is not warranted. ORDER An increased disability rating above the current 10 percent evaluation for the veteran's chronic lymphedema of the lower left extremity is denied. J. E. DAY 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.