Citation Nr: 0214400 Decision Date: 10/16/02 Archive Date: 10/29/02 DOCKET NO. 93-23 870 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for degenerative joint disease, to include left hip replacement. REPRESENTATION Appellant represented by: Kathy Lieberman, Attorney WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD L. A. Howell, Counsel INTRODUCTION The veteran served on active duty from January 1955 to April 1977. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 1991 rating decision of the St. Petersburg, Florida, Department of Veterans Affairs (VA) Regional Office (RO), which denied the claim on the basis of new and material evidence, having been originally denied in February 1989. In December 1995, the Board remanded the case for further development. By decision dated in September 1998, the Board found that no new and material evidence had been submitted and denied the claim to reopen. Thereafter, the veteran appealed the claim to the United States Court of Appeals for Veterans Claims (Veterans Claims Court), which vacated the Board's September 1998 decision and remanded the case due to a change in the new and material evidence law. Subsequently, by decision dated in September 1999, the Board reopened the claim and remanded the case to the RO for further development, including a VA examination and medical opinion on aggravation. In May 2000, the Board denied the veteran's claim for entitlement to service connection, which the veteran again appealed to the Veterans Claims Court. The Veterans Claims Court again remanded the issue and the Board sought further development in February 2002. The requested development has been accomplished, and the case in now returned to the Board for further appellate review. FINDINGS OF FACT 1. VA has made all reasonable efforts to assist the veteran in the development of the claim and has notified him of the information and evidence necessary to substantiate his claim. 2. Medical-judgment evidence and the veteran's own statements indicate that he was treated for a left hip disorder as a child, which has been diagnosed as likely Legg- Perthes disease. 3. In-service medical evidence shows no more than three complaints related to the veteran's left leg/hip throughout his 22 year career and no permanent increase in his pre- existing left hip disorder is shown. 4. Post-service, the veteran first sought treatment for left hip pain in 1985, 8 years after his retirement from service, and was diagnosed with arthritis. He underwent a hip replacement in 1988, after being diagnosed with probable old Legg-Perthes disease. 5. The weight of the medical evidence indicates that the veteran's post-service degenerative joint disease of the left hip was due to the natural progression of pre-existing Legg- Perthes disease. CONCLUSION OF LAW A left hip disorder clearly and unmistakably pre-existed service and was not aggravated by military service; degenerative joint disease of the left hip was not incurred in or aggravated by military service and may not be presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1110, 1111, 1112, 1113, 1131, 1154, 5103(a), 5103A (West 1991 & Supp. 2002); 38 C.F.R. §§ 3.303, 3.304, 3.306, 3.307, 3.309 (2001). REASONS AND BASES FOR FINDINGS AND CONCLUSION The veteran's contentions have been thoroughly described in the previous Board decisions. Briefly, he maintains that service connection is warranted for degenerative joint disease, which ultimately led to a hip replacement. He contends that he injured his left hip while in service when he fell and sustained an injury to his right ribs. He vigorously disagrees with several medical opinions finding a likelihood of Legg-Perthes disease prior to service and that the degenerative arthritis of the left hip was due to the natural progression of the disease. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 1991 & Supp. 2002). If a chronic disease is shown in service, subsequent manifestations of the same chronic disease at any later date, however remote, may be service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b) (2001). However, continuity of symptoms is required where the condition in service is not, in fact, chronic or where diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b) (2001). Further, service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C.A. § 1113(b) (West 1991 & Supp. 2002); 38 C.F.R. § 3.303(d) (2001). Where a veteran served ninety days or more during a period of war or during peacetime after December 31, 1946, and arthritis becomes manifest to a degree of 10 percent within one year of the date of termination of service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. With respect to a claim for aggravation of a pre-existing disorder, a veteran is presumed in sound condition except for defects noted when examined and accepted for service. To rebut this presumption, there must be clear and unmistakable evidence demonstrating that the disability existed before service. 38 U.S.C.A. § 1111 (West 1991 & Supp. 2002). A pre-existing injury or disease will be considered to have been aggravated by service where there is an increase in the disability during service, unless there is a specific finding that the increase is due to the natural progression of the disease. 38 U.S.C.A. § 1153 (West 1991 & Supp. 2002); 38 C.F.R. § 3.306 (2001). 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 service. This includes medical facts and principles that may be considered to determine whether the increase is due to the natural progression 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 (West 1991 & Supp. 2002); 38 C.F.R. § 3.306(b) (2001). Moreover, "temporary or intermittent flare-ups of a pre-existing injury or disease are not sufficient to be considered aggravation in service unless the underlying condition, as contrasted to symptoms, is worsened." Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). However, the increase need not be so severe as to warrant compensation. Browder v. Derwinski, 1 Vet. App. 204, 207 (1991). Nonetheless, silence of the record on this point may not be taken as indication of no aggravation, an opinion must be provided. See Verdon v. Brown, 8 Vet. App. 529 (1996); Wisch v. Brown, 8 Vet. App. 139 (1995). Further, such medical questions must be addressed by medical experts. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). The Board must determine whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either case, or whether the preponderance of the evidence is against the claim, in which case, service connection must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Presumption of Soundness As an initial matter, the Board finds that no pre-service medical records are available. In the most recent Board development, the veteran was asked to provide any information concerning medical treatment he received prior to military service. He related that one physician, who had performed a single home visit, had died in the 1950s or 1960s. He could not recall the name of another physician who had treated him in 1952-53 and the physician had apparently moved to Florida 30 years previously. Nonetheless, it is undisputed that the veteran's January 1955 entrance examination did not mention a pre-existing left hip disorder and his lower extremities were normal. For that reason, he is entitled to the presumption of soundness. Nonetheless, even finding that the presumption of soundness attached at the time of induction, the Board finds, by clear and unmistakable evidence, that the veteran suffered from a pre-existing left hip disorder prior to his entry into military service. Despite the absence of pre-service medical records, the Board is satisfied that medical-judgment evidence and the veteran's own statements provide clear and unmistakable evidence that he suffered from a pre-service left hip disorder, diagnosed as likely Legg-Perthes disease. First, the Board places significant probative value on several post-service reports indicating that the veteran's symptoms were consistent with pre-service Legg-Perthes disease. Specifically, in a May 1985 report, he related a long history of hip pain, which he stated began at childhood; however, he reported that his left hip had not bothered him during 22 years of active duty service. A leg length discrepancy was noted and an X-ray revealed avascular necrosis and collapse of a rather severe stage IV injury with involvement concomitantly of the acetabulum with post-traumatic arthrosis. Moreover, in an April 1988 private medical record, the treating physician noted that the veteran related complaints of hip pain "to an old injury as a child when he fell off a bike." In May 1988, he underwent a left hip replacement. The preoperative diagnosis was severe degenerative arthritis of the left hip with acetabular and femoral head cystic changes. The examiner felt the condition was secondary to an old childhood injury, which was "probably Legg-Perthes disease, left hip." The Board finds this evidence particularly persuasive since it was provided in order to receive treatment and not associated with claim development. The Board also places high probative value on a July 1996 VA examination. Specifically, after examining the veteran and reviewing the claims file, the VA examiner concluded that "it appears [the veteran] had Perthes disease of the left hip as a child." This medical-judgment evidence is also supported by an October 1999 VA examination in which the same VA examiner stated that the medical records indicated an old injury to the left hip as a child with subsequent development of "probable Perthes disease." In the most recent VA examination report dated in May 2002, another examiner noted that the lack of X-ray evidence confirming a diagnosis of Legg-Perthes in childhood spoke again the diagnosis of Legg- Perthes disease but that the post-service X-ray evidence and clinical examination suggested that the veteran's left hip condition was, in fact, secondary to Legg-Perthes disease. Therefore, the Board finds that the weight of the multiple post-service medical reports support a finding that the veteran suffered from Legg-Perthes disease in childhood, prior to entrance onto active duty. In addition, while the veteran at one point during the appeal process denied injuring his hip during childhood, two reports of a private physician, submitted in support of the veteran's claim, appear to concede that the veteran experienced a pre- service hip injury. Of note, in a September 2001 report, the private physician stressed that the veteran's "Perthes' disease was aggravated and made worse" by military service. More recently, the same private physician remarked that the issue was properly characterized as whether military service aggravated the veteran's Legg-Perthes disease. This assertion, by definition, appears to concede the premise that the veteran had Legg-Perthes disease prior to military service. Further, in several duplicative statements received in December 1999 and February 2000, the veteran took issue with an earlier reported medical history. He maintained that he had not injured his hip during childhood when he fell off a bike, but that he had injured the hip when he fell in 1964 during service. He also emphasized that probable arthritis was diagnosed during service. He contended that because the doctors made use of the words "probably" and "possibly," their reports were full of conjecture and speculation. To that end, the Board has considered the equivocal nature of the diagnoses of Legg Perthes disease (the use of terms such as "likely," "probable," etc.). Although absolute certainty in the diagnosis apparently cannot be medically established because no pre-service medical records are available, the Board weighs the absence of absolute certainty against the numerous medical opinions, both VA and private, independently suggesting that the veteran had Legg-Perthes disease as a child and places more probative value on the multiple medical opinions. In addition, the Board notes that the Veterans Claims Court recently held that post-service medical judgment alone may be used to rebut presumption of soundness as long as the evidence is clear and unmistakable. See Jordan v. Principi, No. 00-206 (Ct. Vet. App. Sept. 26, 2002). In this case, the Board is satisfied by the overwhelming medical evidence, albeit somewhat equivocal in nature, that the veteran had Legg Perthes disease prior to his military service. Moreover, the Veterans Claims Court has clearly established that the veteran's own admissions of a pre-service history will constitute clear and unmistakable evidence. Doran v. Brown, 6 Vet. App. 283, 286 (1994). The Board finds that the medical records and the veteran's statements are competent evidence that Legg Perthes disease clearly and unmistakably pre-existed service. Gahman v. West, 12 Vet. App. 406 (1999). The Board observes that the private treating physician and the VA examiners made findings based upon medical principles, which are consistent with 38 C.F.R. § 3.304(b)(1). Further, both the private physician and the VA examiners came to the same conclusion after a review of the clinical evidence and examination of the veteran - that he had Legg Perthes disease as a child. Additionally, the VA examiner made a specific finding that Legg Perthes disease had pre-existed service. Finally, the Board finds that the opinions of the private physician and the VA examiners were consistent with 38 C.F.R. § 3.303(c), which states that there are medical principles so universally recognized as to constitute fact (clear and unmistakable proof), and when in accordance with these principles existence of a disability prior to service is established, no additional or confirmatory evidence is necessary. Moreover, no competent professional has rebutted either the private physician's or the VA examiners' medical determination as to the cause of the veteran's degenerative arthritis in the left hip. As such, after weighing the evidence, including multiple VA examinations, private treatment records, and current VA and private medical opinions, the Board finds that there is clear and unmistakable evidence that the veteran suffered from Legg- Perthes disease prior to his entrance onto active duty and the presumption of soundness is overcome. Having found that the veteran's left hip disorder pre-existed military service by clear and unmistakable evidence, the Board notes that a pre-existing injury or disease will be considered to have been aggravated by service when there is an increase in the disability during service, unless there is a specific finding that the increase is due to the natural progression of the disease. As noted at the outset, however, intermittent flare-ups of a pre-existing disorder are insufficient to be considered an aggravation. Therefore, the threshold questions are: 1) was there an increase in the veteran's pre-existing left hip disorder when he served on military duty, and 2) if an increase is shown, was it due to the natural progression of the disease. Based on the evidence below, the Board finds that the veteran's disorder did not undergo an increase during military service. Increase in Disability During Service Turning first to the issue of whether the veteran's pre- existing left hip disorder underwent a permanent increase during military service, the Board notes that the veteran sought treatment for left leg/hip complaints on three occasions. Specifically, in March 1958, he reported weakness in the extensor muscles of the left thigh after bowling. The impression was questionable hypochondriasis. In September 1958, he reported that his left leg felt weak and caused slight pain and cramps in the lower leg. The examiner stated that the muscle cramps had been occasional in the left calf for three to four days and that it was normal. Thereafter, service examinations dated in October 1958 and January 1959 showed normal clinical evaluations of the veteran's lower extremities. In July 1964, the veteran reported left knee and left hip pain. The clinical impression was "probable arthritis or rheumatoid involvement of knee and hip" but there is no indication of additional follow-up or treatment. Significantly, service examinations dated in January 1965, September 1965, June 1969, June 1974, April 1975, and August 1976, reflect a normal clinical evaluation of the veteran's lower extremities. Moreover, the service separation examination dated in March 1977 also showed a normal clinical evaluations of the veteran's lower extremities. Significantly, in order to support a claim based on aggravation, the veteran's pre-existing condition must be aggravated during active duty. The issue is not whether his condition became worse or is currently worse than it was during military service. To that end, the medical evidence indicates that the veteran's disorder was not, in fact, aggravated during military service. While he reported complaints which could be related to his left hip in March 1958 (left thigh weakness), September 1958 (cramping and weakness in the lower left leg), and July 1964 (left knee and left hip pain), the Board places greater probative value on the absence of a permanent increase in a left hip disorder as evidenced by a normal clinical evaluation of the veteran's lower extremities in service examinations dated in October 1958, January 1959, January 1965, September 1965, June 1969, June 1974, April 1975, and August 1976. The Board also assigns greater probative value to the service separation examination dated in March 1977 showing a normal clinical evaluation of his lower extremities, particularly in light of multiple other disorders noted on the separation examination. Therefore, the Board finds no suggestion of a permanent increase in the veteran's pre-service left hip disorder while he was on active duty. A finding that the veteran's left hip disorder was not permanently aggravated during military service is also supported by the post-service medical evidence showing that he continued to be symptom-free for several years after service separation. Specifically, the Board has reviewed the post-service medical records associated with the claims file and finds no reference to left hip complaints until 1985, some 7 years after service separation. At that time, he related a long history of hip pain beginning in childhood. In April 1988, some 11 years after service separation, he sought treatment for increasing pain in his left hip. The private physician reported that the veteran "relates this to an old injury as a child when he fell off a bike." In May 1988, he underwent a left hip replacement. The pre-operative diagnosis was severe degenerative arthritis of the left hip with acetabular and femoral head cystic changes. The private physician stated that he felt that the current diagnosis was secondary to an old childhood injury, which was probably Legg-Perthes disease, left hip. The Board finds the multi- year gap between service separation and treatment for left hip pain highly suggestive that there was no in-service increase in the veteran's pre-service left hip disorder. The Board is also persuaded by the opinion of multiple VA examiners over the years who have concluded that the veteran's pre-existing left hip disorder did not undergo a permanent increase during service. In the most recent VA examination dated in May 2002 (discussed in greater detail below), the examiner specifically remarked that "the record does not indicate that Legg-Perthes disease, if it existed, progressed at an abnormally high rate during [the veteran's] tour of service." The examiner stressed that he found only three referenced to the veteran's left hip during a 22-year military career, which "[spoke] against any abnormally high rate of progress of the disease during [the veteran's] tour of duty." This is further support by the July 1996 VA examination report which concluded that the veteran's condition was "slow but relentless progression over the years." The Board has also considered two statements from a private physician (discussed specifically in greater detail below), that the veteran's three in-service complaints related to his legs/hips were sufficient evidence to show a permanent increase in his pre-existing disorder. However, the Board places less probative value on the statements of a private physician because the medical opinions are not consistent with the service medical records. Specifically, in statements dated in September 2001 and July 2002, C. Bash, M.D. stressed that the veteran "had three documented visits for hip problems during service, that by definition is onset, therefore the record does support the concept that [the veteran's] hip was made worse or worsened during service- time." The Board does not agree. First, the service medical records do not support the proposition that the veteran sought treatment for hip complaints on three occasions. In March 1958, he reported left thigh weakness but no diagnosis was made related to the hip. In September 1958, he reported cramping and weakness in the lower left leg. Although it could be construed as referred pain, the examiner made no mention of a hip problem. Finally, in July 1964, the veteran, for the first time, reported left knee and left hip pain but no specific diagnosis was made. Therefore, the in-service medical evidence does not necessarily reveal that the veteran sought treatment for hip pain on three occasions. Next, even if his in-service symptoms could be construed to be related to a left hip disorder, the Board places more probative value on the periodic service examinations reflecting a normal clinical evaluation of the veteran's lower extremities. This suggests that any in-service symptoms were acute and transitory. Therefore, the Board finds that three isolated complaints vaguely related to the veteran's left hip, without more, cannot establish an aggravation of a pre-existing disorder. As such, the Board finds that the service medical records do not support findings consistent with an increase in the veteran's left hip disorder. As noted above, to support a claim of aggravation, it must be shown that the veteran's pre-existing disorder was aggravated during military service. As such, the Board is compelled to focus on the period of his service. In this case, it appears that the veteran was symptom-free at the time he entered into active duty, had only three complaints remotely related to his left leg/hip over a 22-year military career, and sought no further treatment until several years after service separation. Accordingly, the Board finds no basis to establish aggravation of a pre-existing left hip disorder during military service. Due to the Natural Progression of the Disorder Next, even if the Board were to construe three complaints related to the veteran's left leg/hip as a permanent increase in severity of a pre-existing disorder, the medical evidence unequivocally reflects that the ultimate increase in his left hip disability necessitating a left hip replacement was due to the natural progression of the disease. Specifically, in a July 1996 VA examination, undertaken specifically to address the issue of aggravation, the VA examiner remarked: From [the veteran's] history, as well as my review of the records, it appears he had Perthes disease of the left hip as a child. It appears this condition slowly but progressively worsened over the years until eventually severe degenerative disease of the left hip developed. He eventually required a total hip replacement in 1988. As to whether this arthritis was related to service by way of incurrence or aggravation, almost certainly this was a slow but relentless progression over the years to the degenerative changes of the left hip due to the old Perthes disease. He now has complaints of pain in the left hip, thigh, and his knee; most likely related to the total hip replacement. Otherwise, I certainly do not think his Perthes disease caused him to have generalized arthritis over his entire body. Similarly, an October 1999 VA examination was undertaken specifically to address the following questions: (1) whether the currently diagnosed left hip condition preexisted service; and (2) if so, is it as likely as not that such left hip condition increased in severity during active service, and (3) if so, whether it is at least as likely as not that such increase in disability was due to, or was beyond, the natural progress of the disease. The same VA examiner was asked also to provide an opinion as to whether it was at least as likely as not that the veteran's left hip disability was incurred in service. After a review of the claims file, the VA examiner stated that the medical records indicated an old injury to the left hip as a child with subsequent development of probable Perthes disease. As to the second question, the VA examiner stated that he felt that the veteran's condition did progressively worsen over the years until eventually severe degenerative disease had developed. Finally, as to the third question, the VA examiner stated that he believed that the increase in severity was compatible with the natural progression of the old Legg Perthes disease. He stated that the degeneration of the hip was slowly progressive and relentless over the years. The VA examiner stated that to say that the increase in severity was "beyond the natural progression" would require, to some degree, conjecture and speculation. Therefore, the Board finds that with a specific finding that any increase in severity of symptoms was attributable to the natural progress of the disease, an award of service connection for a left hip disorder on an aggravation theory is not warranted. Conflicting Medical Opinions Next, as referenced in the discussion above, the Board will specifically consider the three most recent conflicting medical opinions addressing the veteran's claim. First, in a September 2001 private physician letter, Dr. Bash noted that he had reviewed the veteran's service medical records, post- service medical records, rating decisions, statement of the case, and medical literature review for the purpose of making a medical opinion concerning the veteran's left hip Legg- Perthes disease, degenerative joint disease (DJD), and left hip replacement. Dr. Bash concluded that the veteran's Legg- Perthes disease "was aggravated and made worse by his service physical requirements and his advanced DJD was likely caused by his service experiences." He also opined that the veteran's "hip replacement was due to his advanced service induced left hip DJD." Dr. Bash based his opinion on three in-service complaints related to the veteran's left leg/hip, and post-service evidence of a limp, reported history of hip pain beginning in childhood, extensive degenerative osteoarthritis of the left hip, and employment as a welder, requiring him to be on his feet for long periods of time. Dr. Bash maintained that the veteran had several visits to the clinic for left leg problems, and that "it was likely that his left knee complaints were referred from his hip because his knee was normal on several exams," that the veteran had a physically demanding job in service, and that the literature supported a causative association between traumatic episodes/abnormal stress and the development of DJD. Dr. Bash specifically disagreed with the previous medical opinions that the veteran's degenerative joint disease was caused by pre-existing Legg Perthes disease because (i) the VA physicians did not negate the concept that the veteran's service experience aggravated his condition, (ii) no literature was used to support their positions, (iii) the VA physicians "likely did not have fully evaluated the record" as they did not comment on the veteran's complaints of leg pain in 1958, 1964, and 1977, and (iv) the VA physicians inaccurately based their reports on a prior private record reflecting that the veteran's denied problems with his hips during service because, as asserted by Dr. Bash, the veteran's knee complaints were "likely" referred from his hip because his knee was normal on several examination. Second, in a May 2002 VA examination report, the veteran related that he jumped from a bunk in 1958 but did not recall any injury. In 1962, reportedly he ejected in a seat but did not recall any injury. In 1964, he noted he fell on an aircraft and sustained fractured ribs but could not recall whether he complained of hip pain. He retired from the military in 1977, worked as a sheet metal worker for 17 years and retired in 1995. The examiner noted that the veteran first complained of hip pain in 1985 and was diagnosed with arthritis and underwent a left hip arthroplasty in 1988 and a revision in 2000. X-rays showed a total hip arthroplasty with some loosening. X-rays of the left knee, tibia, and fibula were within normal limits. With respect to the veteran's Legg-Perthes disease, the examiner noted that it was a disease of the head of the femur occurring more in males than females and generally having its onset between the ages of three and eight. It resulted in loss of circulation to the bone of the head of the femur and subsequent deformity of the femur head. It could occur with significant symptoms or hardly any symptoms at all. The etiology was unknown. The diagnosis was made by X-ray as well as ruling out other conditions which may present with similar findings such as hypothyroidism and epiphyseal dysplasia. Thirty to forty percent of the children with this condition had a persistent deformity of the head of the femur into adulthood, presenting with the signs and symptoms of arthritis, which could require corrective surgery. The examiner noted that if the veteran had had a bicycle fall as a child, it could have contributed to the deformity of an already diseased femoral head. He noted that the lack of X- ray evidence as a child spoke against the diagnosis of Legg- Perthes disease but the findings on X-ray and clinical examinations prior to hip surgery suggesting that his condition was secondary to Legg-Perthes disease spoke in favor of the condition. He was unable to determined the date on which the Legg-Perthes disease had its onset. The examiner reflected that the record did not indicate that Legg-Perthes disease, if it existed, progressed at an abnormally high rate during the veteran's military service. He noted only three references to complaints related to the veteran's left hip in July 1964, September 1958, and March 1958, during the veteran's 22 years of active duty. He opined that this spoke against any abnormally high rate of progress of the disease during the veteran's military duty. He noted that a VA medical opinion dated in 1996 and a private medical opinion in 1985 supported this opinion and that Dr. Bash challenged the opinion in 2001. The examiner reflected that since Legg-Perthes disease had its onset in early childhood, there was no probability of its having its onset during military service. He noted that one may speculate that the osteoarthritis for which the veteran required surgery in 1988 may have had its onset in service but he noted that this was not supported by the record. He concluded that the medical opinions were expressed after questioning the veteran and examining him and the record and were as unequivocal as medical probability would allow. Third, in a July 2002 follow-up letter, Dr. Bash indicated that he had further reviewed the most recent VA examination report and reflected that the veteran's in-service evidence of osteopenia in the left knee was likely secondary to the veteran's worsening left hip disorder in service. He also noted that the VA physician had done a "nice job" in discussing the pathophysiology of Legg-Perth's disease but it was irrelevant to the veteran's situation. Dr. Bash stressed that the issue was not whether the veteran had Legg-Perthes disease or did it have its onset during service but whether was the veteran's disorder aggravated by military service. Dr. Bash reflected that none of the previous physicians had specifically addressed this issue. He found the May 2002 VA medical opinion that the veteran's osteoarthritis did not have its onset in service "illogical and clearly wrong" on the basis that "three documented visits for hip problems during service, that by definition is onset, therefore the record does support the concept that [the veteran's] hip was made worse or worsened during service-time." Dr. Bash reflected that the May 2002 opinion was invalid because [the VA examiner] does not show that these visits were false or that they were for some other problem or that these visits were protective against advancing arthritis or that [the veteran] did not have arthritis in service or that the physical requirement of service duties are protective of beneficial to a hip that had Perth's disease and he did not provide any literature to support his opinion and he does not provide any literature to contradict the supporting literature that [Dr. Bash] quoted in [his] attached previous opinion . . . Dr. Bash concluded that the previous opinions had not considered the veteran's several visits to medical personnel during service, that he had a physically demanding job in service, the association between stress (standing) and degenerative arthritis, and that they were based on faulty information. He asked that the case be expedited as it had been pending for 17 years. After carefully weighing all three recent medical opinions, the Board is compelled to place more probative weight on the VA examination because it is consistent with the medical evidence of record. Specifically, the Board does not dispute the evidence that the veteran experienced signs and symptoms associated with his left leg/knee in service as this is reasonably supported by the service medical records showing complaints in March 1958, September 1958, and July 1964. However, as noted above, a temporary flare-up of a pre- existing disorder would not be sufficient to establish permanent aggravation. While the Board acknowledges Dr. Bash's opinion that the veteran's disorder would have been aggravated by prolonged standing, his stressful job, and the like, there is no indication of a permanent aggravation during his period of military duty. To this end, the Board places greater probative weight on the service medical records, which clearly show that the clinical examinations of the veteran's lower extremities, including his separation examination, were normal throughout his 22-year military career. Moreover, Dr. Bash does not address the multi-year period between service separation and post-service hip complaints, during which time the veteran was essentially asymptomatic. Therefore, the Board places less significant probative value on Dr. Bash's medical opinion of an in-service aggravation as it is not consistent with the post-service medical evidence showing no permanent increase in the veteran's symptomatology for several years after he was released from military service. As such, the Board assigns Dr. Bash's opinion less probative weight. The Board is also inclined to place less probative value on Dr. Bash's characterization that the VA examinations failed to address the issue of whether the veteran's Legg-Perthes disease was made worse during military service. To the contrary, in an October 1999 VA examination, the examiner specifically concluded that it was "[as] likely as not" that the veteran's hip condition pre-existed service, that the condition "progressively worsened over the years," which was "compatible with the natural progression" of the disease. Even accepting Dr. Bash's characterization that the disorder worsened during military service, his opinion does not contradict the weight of medical evidence that indicates this worsening was the normal progression of the disease. Specifically, while focusing primarily on the issue of whether the veteran's disorder increased in severity during service, Dr. Bash did not specifically address the issue of whether the veteran's ultimate need for a hip replacement was due to the normal progression of Legg-Perthes disease. Every other treating or examining physician who has addressed this issue concluded that the veteran's need for a hip replacement was due to the natural progression of the disorder. For example, as noted above, the October 1999 VA examination remarked that the veteran's condition "progressively worsened . . . until eventually [severe] degenerative disease of the left hip developed." In July 1996, the same examiner remarked that the veteran's "condition slowly but progressively worsened over the years until eventually severe degenerative disease of the left hip developed." He further noted that "this was a slow but relentless progression over the years . . . due to old Perthes disease." Moreover, at the time of the post-service treatment in 1988, the veteran's private physician noted that the X-rays showed "what appears to be an old Legg-Perthes disease with marked mushrooming of the femoral head." Post-operatively, he noted a diagnosis of "severe degenerative arthritis of the left hip with loss of joint space, probably secondary to old [Legg] Perthes disease." The Board has also considered the veteran's own statements that his left hip disorder worsened during military service. His assertions are not deemed to be credible in light of the other objective evidence of record showing no permanent increase in severity during service and no indications of worsening symptoms for many years after military discharge. In the absence of competent, credible evidence of in-service increase in disability, and no post-service treatment for several years after service separation, service connection on the basis of aggravation must be denied. Further, the veteran has alleged that Legg Perthes disease may have healed and that the fall he sustained in service could have re-injured his left hip. He has alleged various bases as to why service connection for degenerative joint disease, to include left hip replacement, is warranted. He refutes the medical findings made by the VA examiner that Legg Perthes disease pre-existed service and was not aggravated in service. However, it has not been shown that he possesses the requisite knowledge of medical principles that would permit him to render an opinion regarding matters involving medical diagnoses or medical etiology. See Espiritu v. Derwinski, 4 Vet. App. 492, 494 (1992). Moreover, there is no medical suggestion that Legg Perthes disease would "heal," as maintained by the veteran. And while he subsequently attempted to refute the medical history he provided to his private physician as to pre-service and in-service left hip injury, the Board finds that the history proffered during the course of medical evaluation and treatment to be more probative. Moreover, the October 1999 VA examiner specifically addressed the issue of whether the veteran's hip was injured at the time of a 1964 fall (when he sustained a contusion to his right ribs). The examiner stated that there was no evidence to suggest that the veteran's left hip was injured at that time. He reflected that it was possible for the left hip to have been injured, but that the veteran had not recalled a hip injury. The VA examiner noted that the veteran asserted that the hip was only "possibly injured" in the fall. The VA examiner stated that to determine that the hip was injured would be resorting to conjecture and speculation. The Board places high probative value on the medical opinion as it directly addresses, but contradicts, the veteran's assertion. Next, the Board is also persuaded that the medical evidence is consistent with Legg-Perthes disease as the Operative Report noted "acetabular and femoral head cystic changes," which is consistent with how the most recent VA examiner characterized the disorder as "loss of circulation to the bone of the head of the femur and subsequent deformity of the femoral head." Moreover, although the veteran's private physician noted "probable" Legg Perthes disease in 1988, he described the condition as a "marked mushrooming of the femoral head," which appears consistent with the general medical description of the disorder outlined in the most recent VA examination report. Therefore, to the extent the veteran claims entitlement to benefits for a left hip disorder on a direct or presumptive basis, the Board finds that the veteran's claim must fail. First, the Board is persuaded by the absence of complaints of, treatment for, or diagnosis of a chronic left hip disorder in service or until many years after his retirement from service. As noted, the service medical records are negative for degenerative joint disease of the left hip as evidenced by normal clinical examinations, although the records note "possible" arthritis, including rheumatoid arthritis, which has never again been suggested. Further, there are no complaints related to a left hip disorder for many years after service separation. As such, the Board finds no evidence of continuity of symptomatology as shown by the multi-year gap between service separation and treatment for a left hip disorder in 1988. Finally, the weight of the medical evidence supports the finding that the veteran's left hip disorder was related to pre-existing Legg Perthes disease, which was not aggravated by military service. Accordingly, the veteran's claim for a left hip disorder on a direct or presumptive basis must be denied. In sum, based on review of all the evidence of record, the Board has concluded that service connection has not been established for either incurrence or aggravation of degenerative joint disease, to include left hip replacement, during service. Finally, in denying the veteran's claim, the Board has considered the Veterans Claims Assistance Act of 2000 (VCAA), which, among other things, redefined the obligations of VA with respect to the duty to assist and included an enhanced duty to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits. The law also eliminated the concept of well-groundedness and is applicable to all claims filed on or after the date of enactment or those filed before the date of enactment but not yet final as of that date. See 38 U.S.C.A. § 5103A (West 2002). Additionally, in August 2001, VA issued regulations implementing the provisions of VCAA "to establish clear guidelines consistent with the intent of Congress regarding the timing and the scope of assistance VA will provide to a claimant who files a substantially complete application for VA benefits." See 66 Fed. Reg. 45620-45632 (Aug. 29, 2001). In this case, VA's duties have been fulfilled to the extent possible with regard to the issue decided in this decision. VA must notify the veteran of evidence and information necessary to substantiate his claim and inform him whether he or VA bears the burden of producing or obtaining that evidence or information. 38 U.S.C.A. § 5103(a) (West Supp. 2002); 66 Fed. Reg. 45,620, 45,630 (Aug. 29, 2001) (to be codified as amended at 38 C.F.R. § 3.159(b)); Quartuccio v. Principi, 16 Vet. App. 183 (2002). By virtue of the information contained in the statement and supplemental statements of the case issued during the pendency of the appeal, the veteran and his attorney were given notice of the information, medical evidence, or lay evidence necessary to substantiate the claim. In addition, the Board informed the veteran by letters dated in March 2002 and June 2002 that his claim was undergoing additional development and his due process rights. Further, it appears that all available medical records identified by the veteran have been associated with the claims file. In addition, he submitted two medical opinions in support of his claim, which have been carefully considered by the Board. Moreover, the claim was the subject of a Board remands in December 1995 and September 1999 and he underwent a recent VA examination expressly for the purpose of addressing the claim on appeal. As such, the Board finds that the record as it stands is sufficient to decide the claim and no additional development is needed. Therefore, the Board finds that the mandates of the VCAA have been satisfied. For the reasons stated above, the Board finds that the preponderance of the evidence is against the claim of service connection for a left hip disorder. Therefore, the claim must be denied. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application in the instant case. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for degenerative joint disease, to include left hip replacement, is denied. Gary L. Gick Member, Board of Veterans' Appeals IMPORTANT NOTICE: We have attached a VA Form 4597 that tells you what steps you can take if you disagree with our decision. We are in the process of updating the form to reflect changes in the law effective on December 27, 2001. See the Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001). In the meanwhile, please note these important corrections to the advice in the form: ? These changes apply to the section entitled "Appeal to the United States Court of Appeals for Veterans Claims." (1) A "Notice of Disagreement filed on or after November 18, 1988" is no longer required to appeal to the Court. (2) You are no longer required to file a copy of your Notice of Appeal with VA's General Counsel. ? In the section entitled "Representation before VA," filing a "Notice of Disagreement with respect to the claim on or after November 18, 1988" is no longer a condition for an attorney-at-law or a VA accredited agent to charge you a fee for representing you