Citation Nr: 0013576 Decision Date: 05/23/00 Archive Date: 05/30/00 DOCKET NO. 97-20 106 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Pittsburgh, Pennsylvania THE ISSUES 1. Entitlement to secondary service connection for arthritis of the right hip. 2. Entitlement to secondary service connection for gout. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD R. T. Jones, Counsel INTRODUCTION The veteran served on active duty from January 1953 to December 1954. This matter comes to the Board of Veterans' Appeals (Board) from a February 1997 RO decision that denied secondary service connection for arthritis of the right hip and gout (both claimed as due to service-connected Crohn's disease). FINDINGS OF FACT 1. The veteran developed degenerative arthritis of the right hip many years after service (for which he has had a total hip replacement). The right hip arthritis was not caused or permanently worsened by a service-connected disability including Crohn's disease. 2. The veteran has not presented competent evidence of a plausible claim for secondary service connection for gout. CONCLUSIONS OF LAW 1. The veteran's right hip arthritis is not proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310 (1999). 2. The claim for secondary service connection for gout is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Background The veteran's established service-connected disabilities (and current ratings) include Crohn's disease (60 percent), kidney stones (30 percent), duodenal ulcer (10 percent), residuals of gallbladder removal (0 percent), and hemorrhoids (0 percent). The veteran served on active duty from January 1953 to December 1954. His service medical records show no arthritis of the right hip or other joint and show no gout. Post- service medical records do not show right hip arthritis or gout until the 1990s. The veteran was admitted Northwest Medical Center in September 1993 for complaints of proximal muscle weakness for approximately 2-1/2 weeks duration. During the admission, he reported he had myalgias for 6-8 months. The impressions were possible active Crohn's ileitis, and diffuse myalgias of unclear etiology. In an August 1994 letter, Michael P. Duncombe, M.D, reported he evaluated the veteran for discomfort in his lower extremities which the veteran said he had for about 1 year. He reported that the veteran was on medication for gout. The veteran's history of Crohn's disease was noted. It was also noted that the veteran had right hip arthritis and might need hip replacement surgery in the future. The impressions were peripheral neuropathy possibly secondary to Crohn's disease, probable nerve root irritation causing left leg discomfort, and arthritis of the right hip. In a September 1994 letter, Dr. Duncombe noted that the veteran had arthritis of both hips, worse on the right side. Outpatient treatment records from Edward E. Engel, M.D., show he saw the veteran in December 1995 for evaluation of joint pains for many years, mostly of the right hip. It was reported that he had been seen a year and half earlier by other doctors and had undergone an MRI. The official report of that study showed no evidence of avascular necrosis, but it was reported that one of the reviewing doctors felt this was present. The assessments were right hip pain, suspect degenerative process, possibly some avascular necrosis; episodic polyarthralgias and tendonitis possibly related to his inflammatory bowel disease; muscular pain and spasm; and Crohn's disease. In later records, Dr. Engel noted the veteran had osteoarthritis of the hips. In February 1996 the veteran was admitted to Horizon Hospital and underwent a right total hip replacement due to degenerative arthritis. During the admission he developed swelling and inflammation of the right great toe. The final diagnoses included osteoarthritis of the right hip, acute gout, Crohn's disease, and a number of other ailments. Private medical records from later in 1996 note osteoarthritis of both hips (with the right hip being replaced) and episodes of gout. In March 1996 the veteran claimed secondary service connection for right hip arthritis (requiring a hip replacement) and gout, and he asserted that both conditions were due to his service-connected Crohn's disease. On a series of VA examinations in April 1996, the diagnoses were Crohn's disease, history of nephrolithiasis, and status post right hip replacement. In April 1996 correspondence, Dr. John F. Steele reported that he first saw the veteran in December 1995 for right hip pain, X-rays revealed degenerative joint disease, and he performed a right hip replacement in February 1996. On a July 1996 VA hip examination, it was reported that that the veteran underwent a right hip replacement in February 1996 for degenerative arthritis. In September 1996 Richard Druyfus, M.D., reported that the veteran had regional enteritis since 1954 that required 3 surgeries, and had a number of stones over the years. In addition he had rather aggressive degenerative arthritis over the last several years. Dr. Dreyfus offered no opinion as to the etiology of degenerative arthritis or any gout. In September 1996 Richard Heibel, M.D., reported on the veteran's cardiac status. The report of past medical history noted that that the veteran had gouty arthritis. On a July 1997 VA intestine examination, it was noted that the veteran had longstanding treatment for Crohn's disease, and had developed kidney stones and arthritis. It was reported that that Drs. Dreyfus and Engel had written letters stating that they felt that that Crohn's disease was responsible for renal problems and arthritis. The impression was Crohn's disease, history of kidney calculi, history of arthritis, and "according to the records" it is felt that the Crohn's disease aggravated the other 2 problems. On a July 1997 VA joints examination, the veteran reported he developed the onset of joint pain over the past 7-8 years. There was no history of trauma. It was noted the veteran underwent a right total hip replacement in February 1996. The doctor said to his knowledge the condition of the right hip was not caused by Crohn's disease. The veteran was admitted to St. Vincent Health Center in March 1998 for a left hip replacement for degenerative arthritis of that joint. In October 1998, the RO returned the two July 1997 VA examination reports for further comments. It was noted the examinations contained conflicting opinions. With reference to the comments on the intestine examination, the RO pointed out that there were records on file showing a relationship between the veteran's Crohn's disease and renal problems (which led to granting secondary service connection for the renal problems) but there were no records of a relationship between the Crohn's disease and the right hip arthritis. In December 1998 the VA doctor who conducted the July 1997 VA joints examination reported that he reviewed the veteran's claims file and found no connection between the veteran's Crohn's disease and the occurrence of the right hip osteoarthritis which had required a total hip replacement. The doctor noted that the right hip problem was due to normal wear and tear of that joint. The doctor noted the conflict in opinions between himself and the VA doctor who conducted the July 1997 VA intestine examination (that other doctor had since retired) and said he had reviewed the case and files with another named doctor who also agreed there was no relationship between the veteran's arthritis and the Crohn's disease. II. Analysis Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Service incurrence will be presumed for certain chronic diseases, including arthritis, if manifest to a compensable degree within the year after active service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. The veteran's right hip arthritis and gout first appeared in the 1990s, many years after his 1953-1954 active duty. It is neither claimed nor shown that direct service connection is warranted for these conditions. Rather, the veteran claims that secondary service connection is warranted for right hip arthritis and gout, and he maintains that such are related to his service-connected Crohn's disease. Secondary service connection may be granted for a disability which is proximately due to or the result of an established service-connected condition. 38 C.F.R. § 3.310. Secondary service connection may be found when an established service-connected condition aggravates (results in an additional level of disability) a non-service-connected disorder. Allen v. Brown, 7 Vet. App. 439 (1995). The veteran's claims for secondary service connection present the threshold question of whether he has met his initial burden of submitting evidence to show that his claims are well grounded, meaning plausible. If he has not presented evidence that his claims are well grounded, there is no duty on the part of the VA to assist him with his claims, and the claims must be denied. 38 U.S.C.A. § 5107(a); Grivois v. Brown, 6 Vet. App. 136 (1994). For the veteran's claims to be plausible or well grounded, they must be supported by competent evidence, not just allegations. Tirpak v. Derwinski, 2 Vet. App. 609 (1992). In order for a claim for service connection to be well grounded, there must be competent evidence of a current disability (a medical diagnosis), of incurrence or aggravation of a disease or injury in service (medical evidence or, in some circumstances, lay evidence), and of causality between service and a current disability (medical evidence). Caluza v. Brown, 7 Vet.App. 498 (1995); Grivois, supra; Grottveit v. Brown, 5 Vet. App. 91 (1993). For a well-grounded claim for secondary service connection, there must be medical evidence of a nexus between an established service-connected condition and the claimed disability. Libertine v. Brown, 9 Vet.App. 521 (1996). A. Right hip arthritis The veteran's claim for secondary service connection for right hip arthritis is well grounded, and the RO has fulfilled its duty to assist the veteran with the development of his claim. 38 U.S.C.A. § 5107(a). The veteran claims that his service-connected Crohn's disease caused or aggravated right hip arthritis that led to his right hip replacement. The medical evidence shows that he developed degenerative arthritis many years after service. A VA doctor who examined the veteran for his service-connected intestinal disorder in July 1997 reported that other doctors had said that the veteran's Crohn's disease was responsible for renal problems and arthritis, and, apparently based on the purported opinions of the other doctors, the VA doctor opined that the Crohn's disease was aggravating the renal problems and arthritis. However, as pointed out by the RO, this opinion is flawed and appears to be based on an erroneous assumption, since there are no medical records on file to show that right hip arthritis is related to Crohn's disease (there are only medical evidence to support secondary service connection for kidney stones.) Two other VA doctors have reviewed the veteran's records and found specifically that that there is no relationship between the veteran's service-connected Crohn's disease and his right hip arthritis. Moreover, other treatment records, including records of the right hip replacement, do not mention Crohn's disease as an etiological factor in the development or level of severity of the degenerative arthritis which led to the right hip replacement. The Board finds the weight of the credible evidence is that the service-connected Crohn's disease neither caused nor permanently worsened (aggravated) the veteran's right hip arthritis. The preponderance of the evidence is against the claim for secondary service connection for right hip arthritis. Thus, the benefit-of-the-doubt doctrine does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski; 1 Vet. App. 49 (1990). B. Gout The threshold question with regard to the claim for secondary service connection for gout is whether the veteran has presented competent evidence of a well-grounded (plausible) claim. Gout was not shown until the 1990s many years after service. No doctor has linked gout to any of veteran's service-connected disorders including Crohn's disease. Although the veteran contends that his gout is related to his service-connected Crohn's disease, as a layman he is not competent to render an opinion regarding diagnosis or etiology of a disability, and thus his statements in this regard do not serve to make the claim well grounded. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). Absent competent medical evidence of a nexus between a service-connected disorder and the diagnosed gout, the claim for secondary service connection must be denied as not well grounded. 38 U.S.C.A. § 5107(a); Caluza, supra; Libertine, supra. ORDER Secondary service connection for arthritis of the right hip is denied. Secondary service connection for gout is denied. L. W. TOBIN Member, Board of Veterans' Appeals