Citation Nr: 0014474 Decision Date: 06/01/00 Archive Date: 06/09/00 DOCKET NO. 90-49 602 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia THE ISSUES 1. Entitlement to service connection for a right hip disability. 2. Entitlement to service connection for a left hip disability. 3. Entitlement to service connection for a low back disability. REPRESENTATION Appellant represented by: Robert V. Chisholm, Attorney at Law WITNESS AT HEARINGS ON APPEAL Appellant and his mother ATTORNEY FOR THE BOARD C. L. Wasser, Associate Counsel INTRODUCTION The veteran served on active duty from January 19, 1970 to August 20, 1970. This case comes to the Board of Veterans' Appeals (Board) from an October 1988 RO decision which denied service connection for a bilateral hip disability, and from a February 1989 RO decision which denied service connection for a low back disability. RO hearings were conducted in March and October 1989. A personal hearing was conducted by a member of the Board at the RO (i.e., a Travel Board hearing) in December 1990. The Board denied the claims in September 1992, and the veteran appealed to the United States Court of Veterans Appeals (now called the United States Court of Appeals for Veterans Claims) (Court). An October 1993 Court order granted a joint motion of the parties to vacate and remand the September 1992 Board decision. The Board remanded the case in March 1994 and, after the case was returned to the Board, an opinion was obtained from an independent medical expert in April 1996. In August 1996, the Board again denied the claims, and the veteran again appealed to the Court. In August 1997, the parties made a joint motion to vacate and remand the August 1996 Board decision, and such motion was granted by an August 1997 Court order. In December 1997, the Board sent a letter to the veteran's attorney, asking him whether he wished to submit any additional evidence or argument. In a December 1997 response, the attorney indicated that additional evidence would be submitted, but he wanted it to be first considered by the RO; he requested that the case be remanded for this purpose. In January 1998, the Board remanded the case to the RO for review of the additional evidence. The case was subsequently returned to the Board. FINDINGS OF FACT 1. The veteran has a congenital or developmental defect of the right hip, for which service connection is prohibited. Even if not a congenital or developmental defect, the right hip condition clearly and unmistakably preexisted active service and there was no increase in severity of the underlying condition on account of service. There is no superimposed right hip disability related to service. 2. The veteran has a congenital or developmental defect of the left hip, for which service connection is prohibited. Even if not a congenital or developmental defect, the left hip condition clearly and unmistakably preexisted active service and there was no increase in severity of the underlying condition on account of service. There is no superimposed left hip disability related to service. 3. The veteran has a congenital or developmental defect of the low back, including osteochondrosis of the lower thoracic vertebrae and spondylolysis of the 5th lumbar vertebra, for which service connection is prohibited. Even if not a congenital or developmental defect, this low back condition clearly and unmistakably preexisted active service and there was no increase in severity of the underlying condition on account of service. Other low back conditions, including arthritis of the lumbosacral spine, were not present during service or within one year after the veteran's separation from service, and were not caused by any incident of service. CONCLUSIONS OF LAW 1. An acquired right hip disability was neither incurred in nor aggravated by active service. 38 U.S.C.A. §§ 1110, 1111, 1153 (West 1991); 38 C.F.R. §§ 3.303, 3.304, 3.306 (1999). 2. An acquired left hip disability was neither incurred in nor aggravated by active service. 38 U.S.C.A. §§ 1110, 1111, 1153 (West 1991); 38 C.F.R. §§ 3.303, 3.304, 3.306 (1999). 3. An acquired low back disability was neither incurred in nor aggravated by active service. 38 U.S.C.A. §§ 1101, 1110, 1111, 1112, 1113, 1153 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.303, 3.304, 3.306, 3.307, 3.309 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual Background A pre-service (April 1967) private X-ray study of the veteran's hips from the Children's Hospital Medical Center shows a steep acetabular roof bilaterally, more striking on the right. The examiner indicated that the hips had lost their normal angulation of the neck to the shaft and were in a valgus position. The right capital femoral epiphysis was laterally placed in the acetabular cavity consistent with valgus hip deformity on that side. There was no evidence of a slipped capital femoral epiphysis, and the deformity seemed to be valgus hips and hypoplasia of the acetabular cavity. A May 1967 X-ray study of the lumbosacral spine shows no evidence of spondylolisthesis. A defect was present in the pars interarticularis of the fifth lumbar vertebra on the right side. The intervertebral space was narrowed between the fifth lumbar and the first sacral segment, and some sclerotic changes were also present. The anterior inferior margin of the eleventh thoracic and the anterior superior margin of the twelfth thoracic vertebra showed aseptic necrosis. The diagnostic impressions were spondylolysis of the fifth lumbar vertebra on the right side, and osteochondroses of the eleventh and twelfth thoracic vertebra. The veteran served on active duty in the Army from January 19, 1970 to August 20, 1970. A review of his service medical records shows that on medical examination performed for enlistment purposes in January 1970, his lower extremities and spine were listed as normal. In a report of medical history completed in conjunction with the enlistment medical examination in January 1970, the veteran denied a history of swollen or painful joints, arthritis or rheumatism, bone, joint or other deformity, and back trouble of any kind. A June 12, 1970 treatment note shows that the veteran was treated after he slipped on the mess hall floor the previous night. On examination, the right hip joint was tender to pressure. An X-ray study of the hips performed that day showed that the acetabular angles were somewhat increased bilaterally, which was associated with slight flattening of the femoral heads bilaterally. The examiner indicated that such changes were felt to be congenital. There was no acute fracture or dislocation. Three days later, the veteran continued to complain of right hip pain. On medical examination performed on June 17, 1970, the veteran's spine was listed as clinically normal. The examiner indicated diagnoses of old congenitally dislocated hips, bilaterally, worse on the right, and traumatic bilateral arthritis, worse on the right. He stated that such conditions were not incurred in the line of duty and existed prior to service. A disqualifying defect was noted, and the veteran's physical profile (PULHES) included L-4 (below minimum standards) for the lower extremities. A June 1970 physical profile record noted that the veteran was found not medically qualified for duty due to old dislocated hips with severe arthritis; training and duty were suspended, pending Medical Board action. An application for expeditious discharge was signed by the veteran on June 18, 1970. The application included the statement that it was understood that he would be separated by reason of physical disability that existed prior to service. A July 20, 1970 Medical Board examination notes that the veteran complained of pain in both hips and his back. He reported that he had painful hips since he was a child, and had a long history of hip and back pain. The veteran reported that prior to enlistment, he had been seen on numerous occasions by orthopedic surgeons, and was advised to undergo an operation. The examiner noted that neither an X- ray study nor an examination of these conditions was performed on induction into military service. On examination, there was tenderness over the right hip, with limited range of motion. An X-ray study showed evidence of arthritis and flattening of the femoral heads, with shallow acetabuli bilaterally. The diagnoses were old congenitally dislocated hips, bilaterally, worse on the right, and bilateral traumatic arthritis, worse on the right. The examiner indicated that the conditions were not incurred in the line of duty, existed prior to service, and rendered the veteran unfit for service. Separation from service was recommended as the veteran did not meet retention standards. Medical records dated on July 28, 1970 show that the veteran was admitted to the hospital after he reportedly fell and hurt his right hip, and had a history of hip dislocation and arthritis. On examination, there was tenderness of the right hip. It was noted that the veteran apparently was born with a congenitally dislocated hip, but was living a rather normal life until he had his first significant problem in mid-June 1970, when he slipped in the mess hall with resultant trauma to the right hip. The veteran reported that at that time, he was carrying trays in the mess hall, when he felt his right leg rotate medially on his foot and laterally on his hip, followed by a severe hip pain which caused him to fall to the floor. After ten minutes, he was able to rise and continue working, but with pain. He reported that he was later treated at the dispensary several times, and was referred to the orthopedic clinic, which diagnosed a congenitally dislocated hip and chronic arthritis, and gave him a limited physical profile. The veteran reported that despite his physical profile, he was ordered to work, and had fallen down the stairs the previous night (the evening prior to being seen on July 28, 1970) with resultant hip trauma. The examiner noted that the veteran reported that his father, uncle, and grandfather were all born with dislocated hips. On examination, the veteran was unable to lift his right leg to hyperflexion; exquisite pain was elicited when the right leg was displaced laterally on the hip, in the area of the femoral head. The veteran was able to walk. An X-ray study showed an old congenitally dislocated hip with arthritic degeneration in the acetabulum; the diagnosis was a congenitally dislocated hip. The examiner prescribed bed rest, and then crutches. An August 1970 treatment note shows that the veteran reported that he was gradually improving. The examiner noted that the veteran still walked with an antalgic gait, and recommended that he continue using crutches. An August 3, 1970 report of Medical Board proceedings indicates that the veteran incurred old congenitally dislocated hips, bilaterally, worse on the right, and bilateral traumatic arthritis, worse on the right, prior to service, and they were not aggravated by active duty. By a statement dated in August 1970, the veteran said that there was no change in his medical condition since his separation medical examination. The veteran was administratively discharged from service on August 20, 1970, pursuant to the Medical Board recommendation. An October 1970 statement of medical examination and duty status [subsequent to the veteran's active duty] shows that on July 28, 1970, the veteran fell downstairs; the injury was described as a stress fracture of the right hip, incurred in the line of duty. It was also reported that the injury was temporary and was not likely to result in a claim against the government for future medical care, and that all information had been taken from official records. In September 1970, the veteran submitted a claim for service connection for a bilateral hip disability. He stated that he developed pain in his hips and back after a five-mile training hike in mid-July 1970. He stated that his claim for service connection was based on aggravation caused by training requirements. The veteran reported treatment in service, as well as treatment by Winthrop Watts, M.D. for childhood disorders. A private medical record, dated in September 1970, from C. G. Brennan, M.D. notes that the veteran was referred by Dr. Watts for evaluation of his hips. In a September 1970 treatment note, Dr. Brennan noted that the veteran had known dysplastic hips as a teenager and on one occasion was told to see an orthopedic surgeon, but reportedly never had any hip pain. He stated that the veteran reportedly slipped and fell during service and injured his right hip, which led to an X- ray study which showed arthritis of the hips, and the veteran was then discharged from service as medically unfit for retention. On examination, the veteran walked with a mild increase in lumbar lordosis, and had knock-knees and a mild duck-waddle gait. Standing erect, the veteran's shoulders and pelvis were level, there was no lumbosacral spine tenderness, and motion was good. On examination of the hips, there was 15 degrees of flexion contracture of the right hip and about 10 degrees of the left hip, and motion was otherwise free. Abduction and adduction were without any real spasm on either side. Leg lengths and muscle mass measurements were equal. An X-ray study showed dysplastic hips bilaterally, with marked valgus with the head uncovered with the legs in a neutral position. He opined that the veteran was a candidate for varus osteotomies, and said the time to do them would really be just before he becomes symptomatic. An October 1970 treatment note shows that the veteran's mother was anxious to proceed with any surgery which might be of assistance in prophylacting the difficulty which the veteran was inevitably going to have with his hips. A November 1970 treatment note shows that the veteran reported right thigh pain at the end of the day and when he was on his feet for long periods of time, but was otherwise doing well. An examination was unremarkable. The veteran had marked internal rotation of both hips but it was painless, and such represented an anteversion. Dr. Brennan opined that surgery was not indicated. In a December 1970 decision, the RO denied service connection for a bilateral hip disability; the veteran was notified of this decision by a letter dated in January 1971, and he did not appeal. By a letter to Dr. Brennan dated in January 1971, H. P. Chandler, M.D., indicated that the veteran was a candidate for a varus derotational osteotomy as he would deteriorate very rapidly unless such was done. In an undated office note, Dr. Chandler noted that the veteran complained of right hip pain of six months' duration. He reported that he was well without any previous symptoms until June 1970, when he performed extensive forced marches during service and began to have right hip pain which had persisted since that time. The veteran reported that his father had hip troubles but did not limp and did not seem to have much pain. The veteran reported that his paternal grandfather and two uncles had hip troubles; one of the uncles had pain and limped. The diagnostic impression was persistent dysplasia of both hips, right worse than left, with persistent anteversion and valgus. Private medical records from the North Shore Children's Hospital reflect that the veteran was hospitalized from February 1971 to March 1971. The discharge summary notes that the admitting diagnosis was congenital dysplasia of both hips, and that the veteran had been followed at that hospital for many years and told that he might require surgery in the future. An intertrochanteric varus angulation derotation osteotomy of the right hip was performed, with compression fixation. A post-surgery X-ray study showed correction of valgus and the head-acetabulum relationship was quite remarkable. The discharge diagnosis was dysplasia of both hips, and right subluxation. By a letter dated in March 1971, a private physician, R. P. Masland, Jr., M.D., indicated that he treated the veteran for a hip problem in 1967. He enclosed copies of X-ray studies (noted above) dated in 1967. He stated that on examination in 1967, the veteran had an exaggerated lumbar lordosis with an unusual, loping gait, slight limitation of flexion of the lumbar spine, and unusual flexibility of the hip joints. Dr. Masland stated that he reviewed the X-ray studies with an orthopedic consultant, and concluded that surgery was not necessary unless the valgus deformity became symptomatic. He stated that it was necessary to follow the veteran periodically with the view of preventing arthritic changes later in life. He said that since the veteran's father and his father's uncle had a similar gait and problems with occasional back pains, they might have similar congenital deformities, and that such indicated a fairly good prognosis in the veteran's case without the necessity for surgery. Dr. Masland indicated that he had discussed the situation with the veteran and informed him that it was all right for him to carry on normal activities and exercise but he should avoid lifting items weighing over fifty pounds. He also recommended that the veteran use a bedboard and sleep on his back or side. Private medical records from Dr. Brennan include a March 1971 treatment note which indicates that the veteran was six weeks status post right hip surgery, and was non-weightbearing on crutches. In April 1971, there was 1/2-inch of shortening of one leg, with good hip motion and a solid union at the osteotomy site. A 1/2-inch heel lift was prescribed for his shoe. The first post-service evidence of complaints referable to the left hip is dated in 1973. An October 1973 treatment note shows that the veteran complained of pain in his left low back and hip. He reported that he had not been wearing his lift and had been doing a great deal of bending, lifting, and straining. On examination, the right pelvis was a little lower than the left, and the veteran was not wearing his lift. An X-ray study showed six lumbar vertebrae with complete sacralization, and complete lumbarization of L1. There was disc space narrowing at the lower level and some facet arthritis at the lowest level. The diagnosis was chronic lumbosacral strain with an underlying developmental problem. Dr. Brennan noted that the veteran was very eager to have a left hip osteotomy done; Dr. Brennan indicated that he did not think the current symptoms would be relieved by such operation. Subsequent medical records reflect treatment for complaints of left hip pain and low back pain. The veteran was hospitalized from July 1974 to August 1974; the admitting diagnosis was arthritis of the left hip. The veteran underwent an elective left osteotomy derotation in varus on his left hip in July 1974 after it began manifesting early symptoms of dysplasia with mild subluxation. An August 1974 note indicates that on admission, the veteran complained of left hip pain and low back pain; Dr. Brennan indicated that he told the veteran his low back pain was not associated with his hip problem. Private medical records dated from 1971 to 1978 from Salem Hospital reflect that the veteran was diagnosed with acetabular dysplasia of both hips, with subluxation on the right side with early degenerative arthritis, some intertrochanteric, and underwent bilateral varus angulation and derotation osteotomies of the hips with compression fixation. A discharge summary shows that the veteran was admitted in February 1971 with a diagnosis of congenital dysplasia of both hips, and indicated that the veteran had been followed at Children's Hospital for many years and was told he might require surgery in the future. It was noted that the veteran was discharged from military service due to bad hips. A January 1976 discharge summary noted that the veteran attempted suicide due to chronic hip pain; the examiner noted that the veteran had excellent health with the exception of congenital dysplasia of both hips which caused him chronic difficulty for most of his life. In February 1978, the veteran submitted an application to reopen the previously denied claim for service connection for a bilateral hip disability, and submitted a claim for service connection for a back disability. He asserted that his bilateral hip disability was aggravated by military service, and related that he had two operations for his conditions. VA outpatient treatment records dated from February 1978 to April 1978 reflect treatment for complaints of low back and bilateral hip pain. A February 1978 treatment note shows that the veteran reported that he had bilateral hip pain for six to seven years, and he underwent a right hip operation in "1970" and a left hip operation in "1975." He complained of increasingly severe back and hip pain. The diagnosis was status post bilateral hip surgery. On orthopedic consultation in April 1978, the veteran reported that during service, he went through basic training for almost seven months, and then was made to lift some heavy military equipment and his back and hips began to bother him. He said he presented for treatment, was told he was unfit, and was discharged. On examination, there was excellent hip motion, and there was grating over the trochanter due to prominent metal inside the hip. His back motions were good, and his leg signs were grossly negative. The diagnostic impressions were a valgus hip corrected by an osteotomy with marked improvement, and one hip with a very shallow acetabulum which was probably aggravated by excessive activity, and low back derangement due to increased lordosis. The examiner noted that the disc at L4-L5 was narrower than that at L3-L4 probably due to minimal degeneration following his acute back strain from heavy lifting in the service. There was no evidence of herniation. The diagnoses were post-operative hips with trochanteric bursitis, and low back derangement secondary to acute back strain with probable degeneration of the L4-L5 disc. By a letter dated in March 1978, Dr. Brennan indicated that he first treated the veteran in 1970 when he presented with complaints of hip problems. He stated that the veteran reported that during service, he slipped and injured his right hip, which led to the performance of an X-ray study, after which he was discharged as being unfit for retention on the basis of his hips. Dr. Brennan stated that at that time the veteran had significant dysplasia of both hips with marked valgus. He noted that the veteran underwent bilateral hip surgeries, and began to complain of back pain in the middle of 1973, and again in 1975. He stated that he did not see the veteran from 1975 until 1978, when he treated the veteran for lumbosacral strain. He noted that the veteran felt he had some type of claim against the Army based on the fact that he began having symptoms while in the service, and such symptoms led to his discharge. Dr. Brennan stated, "I have no idea of the exact mechanics of what went on in that area of time." By statements received in March 1978, the veteran asserted that his back and legs were injured during military service. He stated that he was discharged from service after he was found to be unfit, and that soon after his discharge, he went to a private doctor due to severe pain. He stated that operations were performed on him in 1970 and afterwards, and he currently had back problems and was unable to work. He later asserted that he had medical records dating from grade school which reflected that he had his condition prior to service. He stated that doctors told him he currently needed more surgery. By a statement dated in June 1978, the veteran reiterated many of his assertions. He said that during service he did not slip on the mess hall floor but instead fell off a railing of the stairs to the mess hall. He asserted that he did not have arthritis during service and did not currently have arthritis. He stated that he consulted doctors about his hip condition prior to service, but his only symptom at that time was a slight turning of the knees, and he had no hip pain prior to service. He said he was never advised to have surgery until after separation from service. He asserted that doctors told him his hip condition was aggravated by service, and noted that he had three operations and was scheduled to have two more. A VA hospital discharge summary shows that the veteran was hospitalized from July 1978 to August 1978 for complaints of pain with motion and crepitance over the greater trochanter areas. On admission, the examiner noted that the veteran was fully ambulatory, very athletic and active, and working as a plumber. There was full range of motion of all joints, with pronounced crepitation over the bursa overlying the greater trochanter and plates on each side. Motor, sensory and reflex examinations were all normal. The veteran reported that he occasionally took Percodan or Codeine for hip pain. The veteran underwent removal of metal blade plates from both hips. The discharge diagnosis was congenital dysplasia of the hips, status post bilateral varus derotational osteotomy and fixation with Nigel-Harris blade plates on the right in 1971, and on the left in 1974. An October 1978 follow-up orthopedic note shows that there was full range of motion of both hips, the veteran was able to run and ride a bike for fifty minutes without any problems. The examiner recommended that the veteran avoid contact sports and skiing. In a March 1979 decision, the Board denied service connection for a bilateral hip disability. VA hospital records dated in the 1980s reflect treatment for low back pain. The veteran was hospitalized for four days in March 1980 for complaints of a long history of low back pain with occasional radiation to the right leg. An X-ray study of the lumbosacral spine showed minimal narrowing at the L5- S1 disc space, with lumbarization of S1. The discharge diagnosis was mechanical low back pain. An April 1980 VA outpatient treatment record shows that the veteran reported a long history of low back pain, since 1971 or 1972. He reported that he underwent derotation osteotomies of both hips in 1971 and 1974, and that his low back pain predated his first surgery, and was attributed to his bilateral congenital dislocation of the hips. He reported that his low back pain worsened after his hip surgeries. A subsequent discharge summary shows that the veteran was hospitalized from late April 1980 to early May 1980 for complaints of low back pain. The veteran reported that he had a long history of low back pain dating from 1971 and 1972. An electromyography was performed and was essentially normal. The discharge diagnosis was low back pain. A December 1980 X-ray study of the lumbar spine showed an osteophyte at L1 on the left side with erosion of the inferior surface of the L1 vertebral body, and narrowing at L5-L6, with no evidence of acute fracture. The examiner indicated that the findings were unchanged since March 1980. By letters received in April, May, and July 1980, the veteran reiterated many of his assertions. He stated that although he was born with dislocated hips, he had no medical problems prior to service, but after training in service he started having pain, lost feeling in his legs, and had five operations since 1970. He related that after separation from service, he first sought treatment for his condition within two months. At a July 1980 VA examination, the veteran complained of constant hip and low back pain. He reported a prior medical history of multiple hip surgeries. An X-ray study of the pelvis and hips showed healed osteotomies of both proximal femoral shafts. The right acetabulum showed a slightly increased obliquity, particularly of the roof. A fragment of a needle was present in the base of the greater trochanter of the right femur, and a fragment of a screw was seen in the proximal end of the shaft of the left femur. The diagnosis was residuals of healed osteotomies of the femoral shafts. By a statement dated in January 1981, R. Caldarone said he was the veteran's guidance counselor during junior high school, and he did not recall that the veteran had any physical disabilities at that time which would have prevented him from participating in physical education classes. By a statement dated in January 1981, the veteran reiterated many of his assertions. He stated that his physical condition prior to service was outstanding, and he had no need for treatment of pain. He contended that "extreme physical abuse" of his body during service caused a bilateral hip disability which necessitated surgery. The veteran reiterated these assertions in several subsequent statements, and also contended that he incurred a low back disability during service. By a letter dated in November 1981, a private physician, G. M. Aronoff, M.D., indicated that the veteran had been referred to the pain center for evaluation of constant low back and hip pain. He noted that the veteran's history was obtained from a review of medical records obtained by the veteran from a VA hospital, and from a phone interview. He stated that the veteran was first evaluated in 1967, and referenced medical records from Dr. Trott. He noted that the veteran reported that he was not told of any hip abnormalities at that time, and denied having any difficulty with his hips until seven months into his military service, and said he totally dislocated his right hip during service. He reported that he had been in constant pain since 1971, and reported several hip surgeries. He reported that his pain was so severe that he had contemplated suicide. Dr. Aronoff noted an orthopedic consultation indicated that disc surgery was not appropriate, and recommended that the veteran be admitted to the in-patient program. He stated that he planned to evaluate the possible significance of the veteran's traumatic childhood with an abusive father and what impact it might have had on the veteran's pain and difficulty coping with it. A VA discharge summary shows that the veteran was hospitalized from November 1981 to May 1982 for complaints of low back pain with radiation to the legs. The veteran reported that he underwent hip surgeries in 1970 and 1978, and said his low back pain dated from his original surgery. The veteran was placed in a body cast for several weeks, and his pain was almost resolved by such treatment. In March 1982, a spinal fusion was performed from L4 to the sacrum with a right iliac crest bone graft. The examiner noted that the veteran did well after the surgery. The discharge diagnoses were chronic low back pain, unstable lumbosacral spine, and status post bilateral hip dysplasia. In an addendum, the examiner noted that the veteran had congenital dysplasia of the hips and previously underwent varus derotation osteotomy of the hips, and noted that the veteran reported that he noticed back pain after such surgery. By a letter dated in January 1982, the veteran's representative stated that the veteran wanted to submit a claim for service connection for a low back disability. By a letter dated in March 1982, the veteran stated that he had recently undergone back surgery at a VA facility. In a June 1982 decision, the RO granted entitlement to non- service-connected pension benefits. At a December 1982 Board hearing, the veteran reiterated many of his assertions. He related that he was taken to a doctor when he was about fourteen or fifteen years old because he walked with his toes pointed in and his shoes were wearing unevenly, and several X-ray studies were performed. He stated that he never had any hip problems prior to military service, and had no problems during basic training. He related that he injured his back and hips in a training accident in the field while he was carrying a heavy weight. He said that after the accident, he was told to sit on a rock for the rest of the day until the others finished training, he was taken back to the base on the tailgate of a 21/2-ton truck, and he then returned to the barracks. He stated that he applied for sick call, but he was instead assigned to the mess hall, and later fell off a railing while screwing in a light bulb. He testified that he was then taken to the infirmary, and later hospitalized and placed in traction. He stated that it was only after the second accident that he went to the infirmary, which was about a week after the training accident. He related that he had no symptoms related to his left hip during service. At a March 1984 RO hearing, the veteran reiterated many of his assertions. He stated that he was in perfect physical condition prior to military service, and incurred a hip disability in service. He testified that he dislocated his right hip in the field during a training exercise, and was taken to a hospital in an ambulance and was admitted for this injury. He said he later fell off a railing while screwing in a light bulb. He stated that he was still using crutches when he was discharged from service. He denied incurring any post-service injuries. Records from the Social Security Administration (SSA) reflect that the veteran was awarded disability benefits in May 1984. It was determined that he became disabled in November 1981, and the primary diagnoses were status post lumbar fusion and explosive personality. Multiple medical records, including VA records, are associated with the SSA decision, including a letter from a private physician, P. W. Hugenberger, M.D., who indicated that he examined the veteran in February 1983. He noted that the veteran reported incurring injuries to his low back and both hips during service. He stated that the veteran reported that he ruptured three lumbar discs during service. He said he had reviewed an X-ray study of the veteran's spine from Salem Hospital dated in July 1980, and indicated that there was no question that the veteran had a congenital anomaly of the lumbosacral spine as he had six lumbar vertebrae, and said there might be some arthritis between the sacral vertebra and the first coccyx. The diagnoses were status post fusion of the lumbosacral spine from L4 to the sacrum with complete lumbarization of the first sacral vertebra with residual pain; questionable arthritis involving some of the sacral and sacral coccygeal joints; status post osteotomy of both proximal femurs by history; bilateral mild bow legs; and knee strain. The examiner noted that the veteran refused to undergo an X-ray study. In a January 1984 letter, a VA orthopedic doctor indicated a diagnosis of chronic lumbar instability, and opined that the veteran's impairment was permanent. He noted that the disability was manifested by pain and functional limitations. In an August 1984 decision, the Board denied the veteran's claim for service connection for a bilateral hip disability. In June 1988, the veteran submitted an application to reopen the previously denied claim for service connection for a bilateral hip disability. By a letter dated in January 1989, a private physician, F. A. Graf, M.D., indicated that he evaluated the veteran in October, November, and December 1988, in reference to "injuries sustained in July 1970." He noted that he had reviewed medical records dated from 1974 to 1988. He noted that the veteran reported that he dislocated his right hip in a training exercise while carrying a 65-pound monitor base plate in July 1970, and said he had no back or hip pain prior to this accident, but had low back pain and hip pain ever since the accident. Dr. Graf indicated the following diagnoses: lumbosacral injury, July 1970, bilateral hip injuries, 1970, aggravation of pre-existing congenital hip dysplasia through injury, 1970, chronic lower lumbar intersegmental inflammatory reaction secondary to injury, 1970, with bone reactive change and progressive osteoarthritic change, status post lumbosacral fusion at L4- L5 to S1, L3-L4 hypertrophic osteoarthritic change with probable progressive foraminal stenosis at L3-L4, degenerative disc disease above the levels of surgical fusion, status post osteotomies, proximal femur, with retained fragment, lateral plate fixation screw on the left and trochanteric wire on the right, and early hypertrophic osteoarthritic change of the bilateral femoral heads, with preservation of joint cartilage on the femoral and acetabular surfaces at present. The summary diagnostic impression was dysplastic changes at both hips with poorly covered femoral heads, healed osteotomies of the proximal femur, retained fragment of lateral plate fixation screw on the left and trochanteric wire on the right, solid lumbosacral fusion documented on X-ray study, early hypertrophic osteoarthritic change at both femoral heads with preservation of the joint cartilage of the femoral and acetabular surfaces. Dr. Graf opined that the veteran's ". . . present condition was substantially and predominantly caused by his injury of July 1970 and the surgeries which followed in the management and treatment of that injury. He had a pre-existing condition at both hip joints, i.e., a dysplasia with underdevelopment of the acetabulum bilaterally. This condition predisposed him to the effects of his injury of 1970 with an increased vulnerability to that injury. His lumbosacral condition was caused entirely by the July 1970 injury." At a March 1989 RO hearing, the veteran reiterated many of his assertions. He contended that he had a congenital disability which was aggravated by service, and that he incurred a low back disability during service. He said he was very active prior to service and never had hip pain. He asserted that he injured his hips and low back in a training exercise, and was put on a stretcher and taken to a hospital via ambulance. He testified that he was cut out of his clothes and hospitalized for five or six days. He stated that he was later assigned to work in the mess hall despite his pain and the fact that he was still using crutches, and another soldier instigated a fight. He said that several other soldiers then attacked him and he fell down; he was then taken to a hospital. The veteran's mother testified that she was a registered nurse, and that the veteran had no hip disability at the time when he was examined at Children's Hospital. She said the veteran was very active prior to service, and she recognized that he was having problems after separation from service. She stated that he was a "semi- cripple" when he was discharged from service. She said that as a child, the veteran was never hospitalized prior to service other than for his tonsils. At an October 1989 RO hearing, the veteran and his mother reiterated many of their assertions. The veteran's mother stated that the veteran never had any hip or back problems prior to military service. The veteran testified that he injured his low back in the same training incident in which he injured his hip, he was rendered unconscious due to pain, and was taken by ambulance to the hospital, where he was admitted and placed in traction. By a letter dated in January 1990, the veteran's mother reiterated many of her earlier statements; she asserted that the veteran did not have a lengthy history of hip and back pain prior to service, and said his father and uncle were never treated for hip disabilities. Private medical records from Salem Hospital dated in February 1990 reflect treatment for complaints of back pain. Such records reflect that the veteran reported that he underwent low back fusion and hip surgery due to traumatic injury in service. The diagnosis was musculoskeletal pain secondary to old spinal fusion. In June 1990, the Board remanded the claims for service connection for a bilateral hip disability and a low back disability to the RO for issuance of a supplemental statement of the case with citations to the appropriate law and regulations. By a statement received in December 1990, the veteran's mother reiterated many of her assertions and summarized evidence which was already in the claims file. At a December 1990 Travel Board hearing, the veteran and his mother reiterated many of their assertions. The veteran asserted that he had a congenital condition which was aggravated by military service. The veteran's mother asserted that the only reason he underwent X-ray studies as a child was to rule out any physical conditions prior to a psychiatric evaluation. She stated that when the veteran entered military service he was in good physical condition, but when he was discharged, he was in pain and was limping, and she took him to a doctor within a few weeks after separation. In June 1991, the Board remanded the claims for service connection for a bilateral hip disability and a low back disability to the RO for review of additional service medical records. By a letter dated in November 1991, the veteran reiterated many of his assertions. He essentially stated that he incurred a back disability during service. He stated that his father and uncle did not have hip disabilities. In a September 1992 decision, the Board denied the claims for service connection for a bilateral hip disability and a low back disability. The veteran appealed to the Court. By a statement dated in October 1992, the veteran's father stated that the veteran was not treated for hip or back pain in his early years. He stated that neither he (the veteran's father), his father, nor his uncle was ever diagnosed with or treated for dislocated hips. He related that he was a veteran and had worked as a plumber for thirty years. An October 1993 Court order granted a joint motion of the parties to vacate and remand the September 1992 Board decision. In March 1994, the Board remanded the case in order to obtain pre-service and post-service medical records. By a letter dated in April 1994, a private physician, W. F. Watts, M.D., indicated that he was retired, had no medical records relating to the veteran, and did not recall treating him. He stated that the veteran's records might be located at Salem Hospital or Children's Hospital. By a letter dated in December 1994, a representative from Children's Hospital indicated that he was currently unable to forward any medical records relating to the veteran, and requested that the VA resubmit its information request in one month. In an undated written presentation, the veteran's representative asserted that the veteran had hip and back conditions which existed prior to service, but were asymptomatic at that time. He asserted that such conditions were aggravated by military service. By a letter to Children's Hospital dated in January 1995, the VA requested the veteran's medical records. By a letter dated in February 1995, the veteran's mother reiterated many of her assertions. By a letter dated in March 1996, the Board requested a medical opinion from an independent medical expert (IME) regarding the etiology of the veteran's bilateral hip disability and low back disability, and asked him to opine as to whether there was in-service incurrence or aggravation of such disabilities. By a letter dated in April 1996, a private physician and IME, M. H. McGuire, M.D., stated that he had reviewed the veteran's medical records and had reached medical conclusions. He indicated that the veteran had hip dysplasia of the right and left hips from birth. He opined that arthritis of both hips was present prior to service, and said that arthritis could not have developed during the veteran's 8-month period of military service. He stated that the veteran's in-service falls in June and July 1970 merely provided an opportunity to examine the veteran and establish the degree of arthritis which had developed over a lifetime. He opined that the manifestations of hip pathology during service were only a temporary or acute exacerbation of the pre-service hip disorder, and that no progression would have occurred during his 8-month period of service. He said, "Certainly, no progression beyond the natural course of congenital hip disease, dysplasia and arthritis would have occurred." He indicated that the correct pre-service diagnosis of pathology of the low back was lumbar spinal stenosis, secondary to spondylolysis of the fifth lumbar vertebrae. He opined that at most, the veteran's back symptoms during his period of service would be an acute exacerbation of a lifelong condition. He opined that no injuries beyond the natural progress of the disorder occurred during service in 1970. He concluded, "Base[d] upon my review, and my understanding of the conditions involved, I believe that there is essentially no medical probability that the post-service disability of either hip or the low back was a result of trauma during active service." In August 1996, the Board again denied the claims, and the veteran again appealed to the Court. In August 1997, the parties signed a joint motion to vacate and remand the August 1996 Board decision, and such motion was granted by an August 1997 Court order. By a letter dated in November 1997, a private physician, P. F. Willetts, Jr., M.D., indicated that he reviewed the veteran's medical records. He stated that the veteran sustained an injury to his dysplastic right hip during military service in June 1970, and provided a summary of medical evidence in the veteran's claims file. He indicated the following diagnoses: bilateral congenital hip dysplasia with valgus and femoral flattening of the hips - preexisting; status post aggravation of the right hip while on active duty; status post bilateral varus de-rotational hip osteotomies; pre-existing congenital spondylolysis at L5 on the right, and congenital lumbarization of the first sacral vertebra; pre-existing T-11 and T-12 vertebral body abnormalities - clinically insignificant, and status post surgical fusion of the lumbosacral spine with reported ongoing pain. Dr. Willetts opined that the veteran clearly had pre-existing congenital dysplasia of both hips with abnormalities of both the sockets and femoral heads and proximal femurs existing three years prior to military service, but it appeared that he was asymptomatic except for his abnormal walk until June 1970, when his hip pain began. He reached this conclusion based on Dr. Masland's 1971 letter, and based on the fact that the veteran successfully completed basic training. He stated that the veteran might well have progressed into bilateral hip arthritis regardless of his military service, given the significant hip joint deformities with which he was born. Dr. Willetts stated, "The deterioration of [the veteran's] right hip condition appeared to have been materially and substantially accelerated in excess of what was anticipated by virtue of his injury in June 1970." He noted that there was no contemporaneous indication of left hip or low back complaints at the time of the June 1970 fall. He noted that the veteran had left hip surgery in 1974, and said, "It is not clear whether this left hip injury was directly linked to any accelerated deterioration from his Army duty or not, since the records do not adequately document having such symptoms within a reasonable period of time following his military service." He noted that the veteran first complained of low back pain in October 1973, and said "It is difficult to link this low back pain to his military service, in the absence of contemporary records of such symptoms." He concluded, ". . . there appears to be clear and convincing evidence that military service significantly accelerated the anticipated course of deterioration of [the veteran's] preexisting congenital right hip dysplasia, thus resulting in surgery to the right hip the following year. Linkage to left hip surgery and low back surgery is less clear, however. Although it is possible that basic training and military activities, combined with subsequent post surgical unloading of the right hip did significantly accelerate left hip deterioration, this is not well substantiated in any of the records." In January 1998, the Board remanded the case to the RO for additional development, which was accomplished. II. Analysis The veteran's claims for service connection for a bilateral hip disability and a low back disability are well grounded, meaning plausible. The file shows that the RO has properly developed the evidence, and there is no further VA duty to assist the veteran with his claims. 38 U.S.C.A. § 5107(a). 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. A veteran will be considered to have been in sound medical condition upon entrance into service, except as to defects, infirmities, or disorders noted at entrance, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior to service, and was not aggravated during service. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304. A preexisting disease or injury will be considered to have been aggravated during service when there is an increase in disability during service, unless there is a specific finding that the increase in disability is due to the natural progression of the disease. Clear and unmistakable evidence (obvious or manifest) is required to rebut the presumption of aggravation where the pre-service disability underwent an increase in severity during wartime service. This includes medical facts and principles which may be considered to determine whether the increase is due to the natural progress of the condition. Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306. Neither a bilateral hip disability nor a low back disability was objectively noted on the service entrance examination in January 1970. Thus, the presumption of soundness applies, although it may be rebutted by clear and unmistakable evidence showing pre-service existence of these conditions. The Board finds that such presumption is rebutted as to the bilateral hip disability and the low back disability as the medical evidence clearly and unmistakably establishes that the veteran had bilateral hip and low back disabilities prior to his entrance into active service in January 1970. Such evidence includes pre-service medical records demonstrating the conditions, as well as numerous in-service and post- service medical records which demonstrate that he had a congenital bilateral hip condition and a congenital back condition. Congenital or developmental defects are not diseases or injuries for VA compensation purposes and may not be service connected. 38 C.F.R. § 3.303(c), 4.9. In a precedent opinion, the VA General Counsel noted that such provisions prohibit service connection for congenital or developmental defects (which generally are structural or inherent abnormalities or conditions which are more or less static) but do not prohibit service connection for congenital or developmental diseases. The term "disease" is broadly defined as any deviation from or interruption of the normal structure or function of any part, organ, or system of the body that is manifested by a characteristic set of symptoms and signs and whose etiology, pathology, and prognosis may be known or unknown. Moreover, even though service connection is precluded for congenital or developmental defects, service connection may be granted for disability from disease or injury which is superimposed on the congenital or developmental defect during service. VAOPGCPREC 82-90. Clearly a major portion of the veteran's bilateral hip and low back disabilities involve congenital or developmental defects in the formation of the bones of these joints. This is documented in pre-service X-rays as well as the service and post-service medical records. Congenital hip dysplasia by its very nature is a congenital or developmental defect for which service connection is precluded. In this regard, the Board notes that in March 1971, Dr. Masland, who treated the veteran prior to service, described the veteran's bilateral hip condition as a "valgus deformity" and as a "congenital deformity," and that Dr. Willetts, in 1997, stated that the veteran was born with significant hip joint deformities. As to the low back, the spondylosis at L5 involving the defect in the pars interarticularis is also a congenital or developmental defect for which service connection is precluded. Service connection is only permitted for any superimposed bilateral hip and low back disabilities from in-service disease or injury. Id. A. Right Hip Disability The Board now turns to the question of whether the veteran incurred a superimposed right hip disability during service. Service medical records from the veteran's January 1970 to August 1970 period of service show that the veteran was treated for right hip pain after reportedly falling in June and July 1970. A June 1970 treatment note relates that he was treated after he slipped on the mess room floor the previous night. On examination, the right hip joint was tender to pressure. An X-ray study of the hips performed that day showed that the acetabular angles were somewhat increased bilaterally, which was associated with slight flattening of the femoral heads bilaterally. The examiner indicated that such changes were felt to be congenital. There was no acute fracture or dislocation. On medical examination performed for medical board purposes in mid-June 1970, the examiner indicated diagnoses of old congenitally dislocated hips, bilaterally, worse on the right, and traumatic bilateral arthritis, worse on the right. He stated that such conditions were not incurred in the line of duty and existed prior to service. A July 1970 medical board examination notes that on examination, there was tenderness over the right hip, with limited range of motion. An X-ray study showed evidence of arthritis and flattening of the femoral heads, with shallow acetabuli bilaterally. The diagnoses were old congenitally dislocated hips, bilaterally, worse on the right, and bilateral traumatic arthritis, worse on the right. Medical records dated on July 28, 1970 relate that the veteran reportedly fell down stairs and incurred right hip trauma. An X-ray study showed an old congenitally dislocated hip with arthritic degeneration in the acetabulum; the diagnosis was a congenitally dislocated hip. An August 1970 treatment note shows that the veteran reported that he was gradually improving. The examiner noted that the veteran still walked with an antalgic gait, and recommended that he continue using crutches. An August 1970 report of medical board proceedings indicates that the veteran incurred old congenitally dislocated hips, bilaterally, worse on the right, and bilateral traumatic arthritis, worse on the right, prior to service, and they were not aggravated by active duty. An October 1970 statement of medical examination and duty status [subsequent to the veteran's active duty] states that on July 28, 1970, the veteran fell down stairs; the injury was described as a stress fracture of the right hip. The Board notes that contemporaneous service medical records (including X-ray studies) are negative for an in-service fracture of the right hip, and thus concludes that this post-service statement was in error. Accordingly, the Board concludes that the only right hip disabilities diagnosed in service were a dislocated right hip and arthritis of the right hip; both conditions were characterized as congenital by service doctors. The Board also concludes that the right hip arthritis noted in service is not a superimposed condition incurred in service, but rather existed prior to service. This conclusion is based on the service medical records, and based on the April 1996 IME opinion of Dr. McGuire, who indicated that the veteran's right hip arthritis pre-existed military service as there was no way arthritis could have developed during his 8 months of military service. Post-service medical records reflect treatment, including multiple surgeries (the first one in 1971), for congenital dysplasia of the right hip. There are no post-service medical records reflecting that the veteran incurred a superimposed right hip disability during service. Even if the veteran's right hip disorder were considered to be a congenital disease, rather than a congenital defect, the Board finds that the weight of the evidence demonstrates that there was no permanent aggravation of the pre-existing condition during service (as distinguished from an acute and transitory exacerbation of a pre-existing condition). See Hunt v. Derwinski, 1 Vet. App. 292 (1991) (for a finding of aggravation, there must be an increase in severity of the underlying condition during service, not just intermittent flare-ups of symptoms). Immediately after service, in September 1970, Dr. Brennan indicated that the veteran was a candidate for varus osteotomies, and said the time to do them would really be just before he became symptomatic. This statement indicates that the veteran was not currently symptomatic, particularly in light of Dr. Brennan's subsequent statement that surgery was not currently indicated. Although Dr. Graf (in 1989) and Dr. Willetts (in 1997) both opined that the veteran's pre- service right hip condition was aggravated during service, the Board notes that an IME, Dr. McGuire, opined that the veteran's in-service right hip pathology was only an acute exacerbation of the pre-service hip disorder, and there was no medical probability that the veteran's post-service right hip disability was a result of trauma during service. It is clear that Dr. Graf's opinion is based partly on the veteran's reported history (which differs from the service medical evidence), and that he did not review the veteran's pre-service medical records, service medical records, or post-service medical records dated soon after service. Dr. Graf's opinion has little or no probative value, as it is based on an inaccurate factual premise. Cahall v. Brown, 7 Vet. App. 232 (1994); Reonal v. Brown, 5 Vet. App. 458 (1993). The Board finds that Dr. Brennan's contemporaneous opinion is more probative than that of Dr. Willetts, and concludes that even if the right hip disorder were considered to be a congenital disease, rather than a congenital defect, the weight of the evidence demonstrates that there was no permanent aggravation. The Board notes that the veteran and his representative have asserted that a right hip disability was either incurred or aggravated during his period of active service. As laymen, they are not competent to render an opinion regarding diagnosis or etiology. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). Similarly, the veteran's self-reported lay history, transcribed in some of the post-service medical records, that his right hip disability began in service, does not constitute competent medical evidence of causality. LeShore v. Brown, 8 Vet. App. 406 (1996). The weight of the evidence shows that the veteran has a congenital or developmental defect of the right hip, for which service connection is prohibited. Even if not a congenital or developmental defect, the right hip condition clearly and unmistakably preexisted active service and there was no increase in severity of the underlying condition on account of service. There is no superimposed right hip disability related to service. An acquired right hip disability was not incurred in or aggravated by service. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule does not apply, and the claim for service connection for a right hip disability is denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). B. Left Hip Disability With respect to the question of whether a superimposed left hip disability was incurred in service, the Board notes that service medical records are entirely negative for an injury of the left hip. The records demonstrate treatment for injuries to the right hip, with subsequent X-ray studies of both hips. Such X-ray studies showed that the acetabular angles were somewhat increased bilaterally, which was associated with slight flattening of the femoral heads bilaterally. The examiner indicated that such changes were felt to be congenital. There was no acute fracture or dislocation. The veteran was subsequently diagnosed with old congenitally dislocated hips, bilaterally, worse on the right, and traumatic bilateral arthritis, worse on the right. At a July 1970 medical board examination, the veteran complained of pain in both hips. The diagnoses were old congenitally dislocated hips, bilaterally, worse on the right, and bilateral traumatic arthritis, worse on the right. An August 1970 report of medical board proceedings indicates that the veteran incurred old congenitally dislocated hips, bilaterally, worse on the right, and bilateral traumatic arthritis, worse on the right, prior to service, and they were not aggravated by active duty. Post-service medical records are negative for treatment of a left hip disability until 1973, three years after the veteran's separation from service. The veteran underwent an elective left osteotomy derotation in varus on his left hip in July 1974 after it began manifesting early symptoms of dysplasia with mild subluxation. Subsequent medical records reflect treatment for a left hip disability. As noted above, Dr. McGuire opined that the veteran's bilateral hip arthritis, noted in service, could not have developed during his 8 months of military service, and thus the Board concludes that such arthritis does not constitute a superimposed left hip disability. As there was no injury to the left hip during service, and no other left hip disorders were noted in service, and as the veteran was not treated for a left hip disability until years after service, the Board concludes that a superimposed left hip disability was not incurred in service, and also concludes that the congenital left hip disability (even if considered a disease, instead of a defect) was not permanently aggravated in service. See Hunt, supra. In this regard, the Board notes that the medical evidence does not suggest that during service the underlying left hip condition worsened. Id. The 1996 IME unequivocally opined that a congenital left hip disability with arthritis was not aggravated during service, and in 1997, Dr. Willetts observed that there was no contemporaneous indication of left hip complaints at the time of the June 1970 fall. He noted that the veteran had left hip surgery in 1974, and said, "It is not clear whether this left hip injury was directly linked to any accelerated deterioration from his Army duty or not, since the records do not adequately document having such symptoms within a reasonable period of time following his military service." He concluded that although it was possible that basic training and military activities, combined with subsequent post surgical unloading of the right hip did significantly accelerate left hip deterioration, such was not well substantiated in any of the records. Although Dr. Graf, in 1989, many years after the veteran's separation from service, opined that the left hip disability was aggravated by an in-service injury, it is clear that his opinion was based on an erroneous assumption and erroneous history. He obviously did not review the contemporaneously recorded service medical records because that documentation does not show that the veteran sustained an injury to his left hip or any abnormal clinical findings consistent with functional limitation; there is only one isolated complaint of left hip pain. Dr. Graf's opinion has little or no probative value, as it is based on an inaccurate factual premise. Cahall, supra; Reonal, supra. The Board finds that the opinions of Dr. McGuire and Dr. Willetts are more probative than that of Dr. Graf, as they were preceded by a review of all of the relevant medical evidence, including the veteran's service medical records. The Board notes that the veteran and his representative have asserted that a left hip disability was either incurred or aggravated during his period of active service. As laymen, they are not competent to render an opinion regarding diagnosis or etiology. Espiritu, supra. Similarly, the veteran's self-reported lay history, transcribed in some of the post-service medical records, that his left hip disability began in service, does not constitute competent medical evidence of causality. LeShore, supra. The weight of the evidence shows that the veteran has a congenital or developmental defect of the left hip, for which service connection is prohibited. Even if not a congenital or developmental defect, the left hip condition clearly and unmistakably preexisted active service and there was no increase in severity of the underlying condition on account of service. There is no superimposed left hip disability related to service. An acquired left hip disability was not incurred in or aggravated by service. As the preponderance of the evidence is against the claim, the benefit-of-the- doubt rule does not apply, and the claim for service connection for a left hip disability is denied. 38 U.S.C.A. § 5107(b); Gilbert, supra. C. Low Back Disability As to the veteran's claim for service connection for a low back disability, the Board initially notes that there is X- ray evidence dated in 1967, before the veteran's entry into service, that clearly shows pathology of the lower thoracic and lumbosacral spine, spondylolysis of the fifth lumbar vertebra on the right side, along with osteochondrosis of the eleventh and twelfth thoracic vertebrae. Moreover, in 1983, Dr. Hugenberger indicated that there was no question that the veteran had a congenital anomaly of the lumbosacral spine as he had six lumbar vertebrae. In 1997, Dr. Willett indicated that records showed that the veteran had pre-existing congenital spondylolysis at L5 on the right, congenital lumbarization of the first sacral vertebra, and pre-existing T-11 and T-12 vertebral body abnormalities. Service connection is not permitted for these congenital defects of the back. Service connection may only be established for a superimposed back disability which was incurred in service. The Board finds that the only medical evidence recorded during service to suggest a back disability is a Medical Board report reflecting a complaint of low back pain. However, a low back disability was not diagnosed at that time or at any other time during service. The service medical records are completely negative for any findings that suggest the veteran sustained a low back injury while on active duty. The veteran has testified that he sustained low back trauma during service at the time he injured his right hip, but the contemporaneously recorded service medical records do not corroborate his version of the facts. The isolated complaint of pain in the low back region during service is insufficient to support a finding that a superimposed low back disability was incurred during service. In reviewing the post-service medical evidence of record, the Board notes that the veteran has been treated for a low back disability beginning in 1973, and there is post-service X-ray evidence of arthritis of the lumbosacral spine. Service incurrence for arthritis may be presumed if the disease becomes manifest to a compensable degree within the first year after service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. In this case, however, the veteran's arthritis of the lumbosacral spine was not shown until after the one year presumptive period. As there was no documented injury to the low back during service, and no other low back disorders were noted in service, and as the veteran was not treated for a low back disability (including arthritis) until years after service, the Board concludes that a superimposed low back disability was not incurred in service, and also concludes that the congenital low back disability (even if considered a disease, instead of a defect) was not permanently aggravated in service. See Hunt, supra. In this regard, the Board notes that an April 1978 VA medical record shows that the veteran reported that he injured his back during service; the examiner noted that the disc at L4- L5 was narrower than that at L3-L4 probably due to minimal degeneration following his acute back strain from heavy lifting in the service. Similarly, in a 1989 clinical summary, Dr. Graf opined that the veteran's lumbosacral condition was caused entirely by a July 1970 injury. However, these opinions were based upon the veteran's unsubstantiated, self-reported, history, and the opinion thus has little or no probative value. Cahall, supra; Reonal, supra. This is particularly true where, as here, the service medical records are negative for any history of a low back injury. It is also pertinent to point out that the recent IME opinion concluded that the correct pre-service diagnosis of pathology of the low back was lumbar spinal stenosis secondary to spondylolysis of the fifth lumbar vertebra and, at most, the veteran's back symptoms during service would have been an acute exacerbation of a lifelong problem; the doctor opined that no injuries beyond the natural progress of the disorder occurred during service. Unlike Dr. Graf's unsupported opinion, the IME opinion was based upon a review of the entire relevant medical evidence of record, including the service medical records. Similarly, Dr. Willett, who reviewed the veteran's medical records in 1997, noted that the veteran first complained of low back pain in October 1973, and said "It is difficult to link this low back pain to his military service, in the absence of contemporary records of such symptoms." The Board notes that the veteran and his representative have asserted that a low back disability was either incurred or aggravated during his period of active service. As laymen, they are not competent to render an opinion regarding diagnosis or etiology. Espiritu, supra. Similarly, the veteran's self-reported lay history, transcribed in some of the post-service medical records, that his low back disability began in service, does not constitute competent medical evidence of causality. LeShore, supra. The weight of the evidence demonstrates that the veteran has a congenital or developmental defect of the low back, including osteochondrosis of the lower thoracic vertebrae and spondylolysis of the 5th lumbar vertebra, and such may not be service connected. Even if not a congenital or developmental defect, this low back condition clearly and unmistakably preexisted active service and there was no increase in severity of the underlying condition on account of service. Other low back conditions, including arthritis of the lumbosacral spine, were not present during service or within one year after separation from service, and were not caused by any incident of service. An acquired low back disability was not incurred in or aggravated by service. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule does not apply, and the claim for service connection for a low back disability is denied. 38 U.S.C.A. § 5107(b); Gilbert, supra. ORDER Service connection for a right hip disability is denied. Service connection for a left hip disability is denied. Service connection for a low back disability is denied. L. W. TOBIN Member, Board of Veterans' Appeals