BVA9504578 DOCKET NO. 92-10 412 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUE Entitlement to service connection for a bilateral foot disorder. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD E. A. Artman, Associate Counsel INTRODUCTION The veteran served on active duty from July to December 1989. This matter comes before the Board of Veterans' Appeals (Board) of the Department of Veterans Affairs (VA) on appeal from a December 1990 rating decision of the Denver, Colorado, Regional Office (RO). This decision denied a claim of service connection for bilateral pes planus, after the veteran filed a claim for benefits due to foot pain incurred in service. During the course of his appeal of the December 1990 rating action, this case has been returned to the RO by the Board for additional development of the evidence. This remand occurred in February 1993. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that he had no trouble with his feet prior to his entry into active service; that, while in the service, he began to experience sharp pain in both feet on lengthy marches; and that this pain has continued since his discharge, resulting in an inability to stand on his feet for prolonged periods of time. 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 in favor of the veteran's claim of service connection for bilateral pes planus and right hallux valgus. FINDINGS OF FACT 1. All facts pertinent to the veteran's claims have been fully developed for purposes of adjudication. 2. A June 1989 entrance examination report establishes, along with the veteran's assertions to like effect, that pes planus was present, although asymptomatic, prior to his period of active service. 3. The veteran complained of bilateral foot pain while on active duty, which was attributed to his pes planus and resulted in a recommendation that he be released from active service through administrative channels. 4. Tenderness of the metatarsals and pronation were demonstrated during service, indicative of increased disability. 5. Right hallux valgus was first shown during service. CONCLUSION OF LAW The veteran's preexisting bilateral pes planus was aggravated during his active (peacetime) service and right hallux valgus was incurred therein. 38 U.S.C.A. §§ 1131, 5107, 7104 (West 1991); 38 C.F.R. §§ 3.303, 3.306 (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSION A review of available service medical records shows that, upon entry into active service, the veteran was found to have pes planus, characterized as mild and asymptomatic. The fifth toes were elevated. Report of Medical Examination (June 30, 1989). He complained of bilateral foot pain in August 1989 (at which time X-ray studies disclosed no abnormalities of the left foot) and again in November 1989. At a November 30, 1989 consultation by a podiatrist, there was good ankle subtalar midtarsal range of motion, contracture of the left lesser toe and pronation of the foot. It was concluded that there was questionable function, but probable functional pes planus, and that he should be discharged through administrative channels. Such action took place the following month (no separation examination is of record). In April 1990, the veteran's feet were examined by VA for the first time. At the examination, the veteran stated that he continued to experience bilateral foot pain following his discharge from the service, particularly after prolonged periods of standing. The examiner noted that the veteran had a normal toe-heel and tandem gait, ankle dorsiflexion from 0 to 10 degrees and ankle plantar flexion from 0 to 45 degrees. No calluses of the feet were detected, although a right hallux valgus was present. Bilateral pes planus was also noted to be present upon physical examination. X-ray studies completed at the time of examination were negative for abnormalities of either foot. Consequently, the examiner's diagnosis was one of bilateral pes planus and right hallux valgus on clinical examination, with negative X-ray findings and with signs and symptoms as recorded. By contrast, the veteran's private podiatrist, Paul Stone, D.P.M., found his bilateral foot disorder to be more pronounced. In a March 18, 1991 treatment report, he described the veteran as having a collapsing pes valgus with a flexible flat foot overcompensated by subtalar joint pronation. In addition, he found that the veteran's heel had developed a valgus attitude on stance and that he had an internal rotation of the tibia. An obvious plantar fasciitis secondary to hyperpronatory gait was also noted. Dr. Stone performed X-ray studies at a May 5, 1991 treatment, which he then reported as showing severe collapsing pes valgus with anterior dislocation of the cyma line and no evidence of tarsal coalition either at the posterior, middle or middle facet of the subtalar joint or at the calcaneal navicular area on the oblique view. The records contains a more recent treatment report from Dr. Stone, which is dated February 10, 1994. In this report, he states that he was continuing to treat the veteran's very severe pes planus with a combination of orthotic devices, physical therapy and exercise. He added that, in his opinion, the veteran was beginning to develop degenerative changes in his left ankle and subtalar joint with a grading and clicking on range of motion. Dr. Stone stated that the veteran's severe pes planus had improved slightly with orthotic supports, and that the veteran also had severe plantar fasciitis with tendonitis, which prevented the veteran from working in a standing or walking capacity. One month prior to the date of Dr. Stone's report, in January 1994, the veteran's feet were examined by VA for a second time. The examiner noted that the veteran was then employed as a cook. It was further noted that the veteran complained of daily pain, for which he occasionally took Motrin. It was noted that the left foot hurt more than the right, and that the veteran was unable to run or walk long distances. The veteran stated that his feet began to hurt if he stood for longer than a hour, and that he had discussed with Dr. Stone the possibility of corrective surgery. Physical examination revealed that the veteran had moderately severe bilateral pes planus with significant loss of the longitudinal arch of the feet. In addition, a few calluses were present on the metatarsophalangeal joints of the first and second toes bilaterally, although no other toe deformities could be found. The veteran's gait was normal. X-ray studies performed the day of examination provided impressions of metatarsus planus varus with hallux valgus deformities of both feet, found to be slightly more prominent on the right than the left, and flexed positioning of toes two through five bilaterally. Based on his findings, the examiner provided a diagnosis of moderately severe bilateral pes planus with residuals of discomfort as noted. In a July 1994 report, Dr. Stone indicated that the veteran's feet became symptomatic during basic training due to the long hours of marching and other requirements of basic training. It was Dr. Stone's opinion that the marching and other requirements of basic training were the primary cause of the permanent increase in severity that had continued in civilian life. It was pointed out that the veteran's history was consistent with an increase in symptomatology after enlisting in the military service and that review of some records supplied by VA pointed out some willful miscalculations. Specifically, it was pointed out that, although X-rays had shown no significant abnormality, the films would have to be taken in full weight bearing in angle and basive gait in order to show the compensatory hyperpronation of the subtalar joint or midtarsal oblique and longitudinal axes. Before assessing the merits of the veteran's claim, the Boards notes that it finds the claim to be well-grounded for purposes of 38 U.S.C.A. § 5107(a). That is to say, the veteran has submitted a claim which is plausible, as supported by the requisite competent medical evidence to that effect. See Grottveit v. Brown, 5 Vet.App. 91 (1993). Furthermore, we find that VA has met its duty under § 5107(a) to assist the veteran in the development of all facts pertinent to his well-grounded claim. See Grottveit at 93. Thus, the claim of service connection is adequately developed for purposes of appellate adjudication. By law, service connection may be established for disability resulting from an injury suffered or disease incurred in or aggravated by the line of duty. 38 U.S.C.A. § 1131 (West 1991). Each disabling condition shown by a veteran's service records, or for which he seeks a service connection must be considered on the basis of the places, types and circumstances of his service as shown by service records, his medical records, and all pertinent medical and lay evidence. 38 C.F.R. § 3.303(a) (1993). In the present case, the veteran's service entrance physical examination establishes the preservice existence of pes planus. In order to establish service connection for a preexisting disorder, there must, initially, be shown an increase in disability during service. The history given by the veteran at service entrance and in the postservice years is that his pes planus was asymptomatic until he engaged in the rigors of basic training. Service medical records document his continued complaints of foot pain, beginning slightly more than one month after service entrance. A podiatry examination during service revealed the first evidence of pronation, which represents an organic or structural change to the feet and is sufficient to constitute an increase in disability of the preexisting disorder. Where there is an increase in severity of the preexisting disability, there must be clear and unmistakable evidence (obvious or manifest) to rebut the presumption of aggravation. Medical facts and principles may be considered in determining whether the increase in severity is due to the natural progress of the condition. 38 C.F.R. § 3.306(b). The only evidence on this point which is currently before the Board is the unrefuted opinion of the veteran's podiatrist. He has stated that the primary cause of the increase in severity of the veteran's pes planus was the required long hours of marching and other physical training during basic training. This evidence certainly does not clearly and unmistakably establish that the veteran's pes planus would have increased in severity notwithstanding military service. While there appears to have been a continued progression of symptomatology subsequent to service, natural progress of the disorder during service has not been established. Accordingly, the preponderance of the evidence favors a grant of service connection for bilateral pes planus, on the basis of inservice aggravation. Service medical records also establish the presence of right hallux valgus. This disorder is not shown to have been of preservice origin and has continued to be shown subsequent to discharge. As a result, the preponderance of the evidence favors a grant of service connection for this disorder. ORDER Service connection for bilateral pes planus and right hallux valgus is granted. BARBARA B. COPELAND 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.