Citation Nr: 1306086 Decision Date: 02/21/13 Archive Date: 02/27/13 DOCKET NO. 06-29 964 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUE Entitlement to service connection for bilateral hip disability, including as secondary to a service-connected disability. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD M. Young, Counsel INTRODUCTION The Veteran served on active duty from November 1982 to November 1986. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2006 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA). Although the Veteran requested a Board hearing in September 2006, he failed to report for his scheduled February 2010 hearing. This matter was previously remanded by the Board in March 2010, December 2010 and July 2012. The Board notes that issues of entitlement to service connection for bilateral knee disability were also remanded by the Board in March 2010. In a September 2010 rating decision, the RO granted entitlement to service connection for patellofemoral syndrome of the right and left knees. The grant of service connection for patellofemoral syndrome of the right and left knees constituted a full award of the benefit sought on appeal as to those issues. Thus, the issue of entitlement to service connection for bilateral knee disability is no longer in appellate status. FINDING OF FACT The Veteran does not have a chronic bilateral hip disability which is causally related to active duty service; the Veteran does not have a chronic bilateral hip disability which is causally related to a service-connected disability, to include by aggravation. CONCLUSION OF LAW Chronic bilateral hip disability was not incurred in or aggravated by the Veteran's active duty service, nor is chronic bilateral hip disability proximately due to or caused by a service-connected disability. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) Under the VCAA, codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107 and 5126; see also 38 C.F.R. §§ 3.102, 3.156(a), and 3.326(a), VA has a duty to notify the claimant of any information and evidence needed to substantiate and complete a claim, and of what part of that evidence is to be provided by the claimant and what part VA will attempt to obtain for the claimant. 38 U.S.C.A. § 5103(a); 38 C.F.R § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Duty to Notify The record shows that in October 2005 and December 2005 VCAA letters, the Veteran was informed of the information and evidence necessary to warrant entitlement to the benefits sought on appeal. The October 2005 letter included notice specific to a claim of service connection on a direct basis; and the December 2005 letter included notice specific to a claim of entitlement to service connection on a secondary basis. The Veteran was also advised of the types of evidence VA would assist him in obtaining as well as his own responsibilities with regard to identifying relevant evidence. See Quartuccio, 16 Vet. App. 183; Charles v. Principi, 16 Vet. App. 370 (2002). The United States Court of Appeals for Veterans Claims' (Court) decision in Pelegrini v. Principi, 18 Vet. App. 112 (2004) held, in part, that a VCAA notice as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim for VA benefits. In this case, the RO provided VCAA notice to the Veteran in October and December 2005, which was prior to the June 2006 rating decision. Accordingly, the requirements the Court set out in Pelegrini have been satisfied. On March 3, 2006, the Court issued a decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), which held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. The Court held that upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Id. at 486. Additionally, this notice must include notification that a disability rating and an effective date for the award of benefits will be assigned if the benefits are awarded. Id. at 488. In this case, a supplemental statement of the case sent in August 2010 provided the notice contemplated by Dingess. The Veteran was provided with notice of the types of evidence necessary to establish a disability rating and an effective date for any rating that may be granted, and the notice explained how VA determines disability ratings and effective dates. Any defects as to the timeliness of the statutory and regulatory notice are rendered moot because the Veteran's claim on appeal have been fully developed and re-adjudicated by an agency of original jurisdiction after notice was provided. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). In sum, the Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of his claim, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). In any event, the Veteran has not demonstrated any prejudice with regard to the content of the notice. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009) (Reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination.) See also Mayfield, 444 F.3d at 1333-34. Duty to Assist The Board finds that there has been compliance with the assistance provisions set forth in the law and regulations. All available pertinent records, including in-service treatment reports (STRs) and postservice VA medical reports, have been obtained. The Veteran's Virtual VA file has been reviewed and there were no pertinent records found that are not already associated with the claims file. The Veteran was afforded VA examinations, pertinent to his bilateral hip disability, in April 2006, May 2009, May 2010, March 2011, and August 2012. Unfortunately, the Board found that the April 2006 VA examination inadequate, given that the examiner did not offer an opinion as to whether the Veteran's bilateral hip disability had been aggravated by his service-connected bilateral ankle disability. The May 2009 examination included examination of the hips, however, a nexus opinion regarding the Veteran's claimed bilateral hip disability was neither requested nor provided; and the matter was remanded for the Veteran to undergo another examination. Pursuant to the Board's March 2010 remand instruction, the Veteran was afforded a VA medical examination in May 2010. The Board found that examination report inadequate and remanded the matter to schedule the Veteran for another VA medical examination, which was held in March 2011. In a December 2010 Board remand, the Board found the March 2011 VA medical examination inadequate and ordered another examination to be scheduled. The Appeals Management Center arranged for a VA medical examination of the Veteran in May 2012, and informed him by letter (dated May 14, 2012) that he would be notified by a VA medical facility near him to schedule an examination in connection with his claim. Subsequently, the examination request was cancelled. In a June 2012 note attached to the claims file it was noted that the examination requested was cancelled because the Veteran hung up on the person (from VA) that called him on May 23, 2012 to inform him that he needed to be seen for another examination. The Veteran was subsequently provided a supplemental statement of the case, which discussed the reason for cancelling the examination, and he was given an opportunity to respond. There had been no response from the Veteran regarding the matter. The matter was again remanded in July 2012 to afford the Veteran another VA examination. An examination was conducted in August 2012. The Board finds there has been substantial compliance with its most recent remand. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998) where Board's remand instructions were substantially complied with). VA has complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision on the claim at this time. Legal Criteria, Factual Background and Analysis Initially, the Board notes all of the evidence in the claims file, with an emphasis on the evidence relevant to this appeal, has been reviewed. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claim. Applicable law provides that service connection will be granted if it is shown that the Veteran suffers from disability resulting from an injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury or disease in line of duty, in the active military, naval, or air service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. That an injury occurred in service alone is not enough; there must be chronic disability resulting from that injury. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). 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 C.F.R. § 3.303(d). Secondary service connection is warranted where a disability is proximately due to, or the result of, or aggravated by a service-connected disease or injury. Establishing service connection on a secondary basis requires: (1) competent evidence (a medical diagnosis) of a current disability (for which secondary service connection is sought); (2) evidence of a service connected disability; and (3) competent evidence that the current disability was either (a) caused or (aggravated) by the service connected disability. 38 C.F.R. § 3.310(a); see also Allen v. Brown, 7 Vet. App. 439 (1995)(en banc). Effective October 10, 2006, 38 C.F.R. § 3.310 was revised to implement the Allen decision. The revised 38 C.F.R. § 3.310 institutes additional evidentiary requirements that must be satisfied before aggravation may be conceded and service connection granted. In essence, it provides that in an aggravation secondary service connection scenario, there must be medical evidence establishing a baseline level of severity of disability prior to when aggravation occurred, as well as medical evidence showing the level of increased disability after aggravation occurred. As the Veteran's claim was pending prior to the effective date of the revised 38 C.F.R. § 3.310, the Board will consider the version in effect prior to October 10, 2006, as it is more favorable to the claimant. See Kuzma v. Principi, 341 F. 3d 1327 (Fed. Cir. 2003); VAOPGCPREC 7-2003. The Veteran has claimed entitlement to service connection for a bilateral hip disability to include as secondary to his service-connected bilateral ankle disability. Since service connection has been granted for bilateral knee disability (during this appeal period), a theory of service connection for a bilateral hip disability secondary to the bilateral knee disability has been raised and the Board will address such matter in this decision. The Board notes that the Veteran is not prejudiced by the Board's consideration of the matter of service connection secondary to the bilateral knee disability as the RO adjudicated the matter in the first instance in the January 2013 supplemental statement of the case. The STRs, in pertinent part, documented a January 1983 complaint by the Veteran of pain in the hips for three weeks. The impression was stress of "BCT". STRs make no further mention of any problems associated with the Veteran's hips. A June 1989 postservice VA treatment record notes that the Veteran, who was service-connected for an ankle injury presented with his wife with complaints of a back injury that happened at work. He reported that the pain was located around the right hip area. There was no assessment/diagnosis rendered, especially as related to the hips. On December 2002 VA [fee basis] examination of the musculoskeletal system, (which primarily focused on the Veteran's ankle disability) the Veteran's posture and gait were normal; there were no signs of abnormal weight bearing. He did not use assistive devices to ambulate. There was no mention of any disorder associated with the hips. In September 2005 the Veteran filed a claim for service connection for a bilateral hip disability. In a written statement, received at the RO in November 2005, he noted that his bilateral hip disability is secondary to his service-connected left and right ankle disabilities. A January 2006 VA outpatient treatment report shows the Veteran was seen with complaints of knees and hip pain. The assessment was generalized joint pain of the neck, back, ankle, knee, hip, and left elbow. On April 2006 VA (fee basis) examination, the Veteran reported that his bilateral hip disability had existed four years, and was not due to injury. He stated that it had occurred secondary to bad gait or stance, posture and workload due to his ankles. He reported such symptoms as occasional stiffness of the hips, lack of endurance, tiring easily, locking, popping, and pain. X-rays of the left and right hips revealed findings within normal limits. Following a physical examination, the diagnosis was bilateral hip bursitis with hyperflexability. The examiner noted that the subjective factor was a history of pain; the objective factors were negative x-rays and evidence of bilateral tenderness and hyperflexed range of motion on examination. The examiner opined that it is as least as likely as not that the Veteran's bilateral hip condition is secondary to the bilateral ankle injury. He further noted that it is not likely that the bilateral hip condition is related to the right ankle condition. In an April 2006 addendum the examiner provided a rationale for his opinion. He noted that per the March 1986 emergency care and treatment record, the Veteran had a motor bike injury that resulted in a right ankle sprain. There was no other mention of a bilateral hip problem noted in service records, or postservice records from May 2005 to January 2006. The Veteran presented with bilateral hip hyperflexion range of motion, which the examiner concluded was most likely the cause of the Veteran's bilateral hip condition, not the right ankle disability. VA examination in May 2009 revealed the Veteran had good posture, good physical development, normal gait without any limp and he did not use any walking aids. There was no diagnosis associated with the hips rendered at that time. In a May 2010 VA examination report, the examiner noted review of the claims file. The Veteran reported that he started having pain to the hips three years postservice. He stated that the pain to his hips is related to his ankles. X-rays taken of the hips were negative. Following examination of the hips, the diagnosis was normal examination of the bilateral hips. The examiner opined that the Veteran's bilateral hip disability is not causally related to military service or a result of, or aggravated by his service-connected right and left ankle disabilities. By rationale the examiner explained that the Veteran had no complaints of hip problems while in service. The first documented problem to his hips was dated in December 2005 when he called his primary care physician to complain of the problem. At that time, he had a normal examination with range of motion and he had the same at a January 2006 follow-up appointment. There was no documentation of any other complaints to his primary care physician or of any other treatment. That one complaint showed no sequela and or a lack of chronicity. There was no nexus or causal relationship to military service, or a result of, or aggravation by the Veteran's service-connected right and left ankle disabilities. The Board found this examination inadequate because in reaching a conclusion in this matter, the examiner cited inaccurate data. Specifically he stated that the Veteran had no complaints of or treatment for hip problems while in service, and the evidence shows that he was in fact seen in service in January 1983 for complaints of hip pain. The Board remanded the matter to schedule the Veteran for another examination. On March 2011 VA examination (pursuant to Board remand), the examiner noted review of the claims file. In describing the circumstances and initial in-service manifestation of his bilateral hip disability, the Veteran reported that he had just arrived in Hawaii and was hit by a wave, and had pain in his left hip, but he was not sure if the pain was in his hip or his back. He stated that he waited until he could walk and then he got out of the water. He could not recall when it was that he was treated after the incident, or whether his hip was x-rayed, or when he returned to regular duty. However, he stated that his hips were better in the following weeks. He stated that the problem (with his hips) reoccurred in the mid 1990's following a motor vehicle accident in 1992. At that time, he injured his neck primarily. Following physical examination, the diagnosis was ligamentous laxity of multiple joints including the hips, knees, and ankles. The examiner noted that further diagnosis was not possible without the studies that were ordered. On August 2012 VA examination, it was noted that the claims file had been reviewed. On examination he was diagnosed as having normal bilateral hips and stable joint. X-rays of the hips revealed a negative examination. There were no osseous, articular or soft tissue abnormalities seen. The examiner opined that the Veteran's bilateral hip disability is less likely than not (less than 50 percent probability) incurred in or caused by an in-service injury, event or illness. He further opined that the Veteran's bilateral hip disability is less likely than not (less than 50 percent probability) proximately due to or the result of a service-connected disability. The examiner's rationale for the opinion was that the Veteran's hip examination was normal age senescence without osseous or articular change. He stated that the Veteran's problem was his low back. Further, he noted that the Veteran does not have expertise in medical anatomy or regional anatomy but he speculates, from hearing on television, how the relationships of cause and effect occur and base his statement in support of his claim on what he has heard. He has stated that someone in his past proposed instability and how it works on all joints and the spine, and he speculates that is the cause of his hip problems by way of his other extremities. The examiner noted that there is no medical evidence to support the Veteran's normal hip examination and normal radiographs. His imaging and physical are normal; and there was no pathology. The Board notes that the Veteran initially claimed service connection for a bilateral hip disability as directly related to service. While STRs show an impression of stress of "BCT", associated with the Veteran's complaint of pain in the hips for three weeks during basic training (January 1983), there is no suggestion of a chronic bilateral hip disability in service. This supports a finding that the Veteran's complaint of hip pain during service was acute and transitory with no residuals. There is no evidence that a chronic bilateral hip disability was either incurred in or aggravated by his active duty service. Furthermore, the preponderance of the evidence indicates that while the Veteran had right hip pain in service, he does not have a current bilateral hip disability. On May 2010 VA examination x-rays of the hips were negative and the diagnosis was normal examination of the hips. On the latest VA examination (August 2012) the Veteran was diagnosed as having normal bilateral hips and stable joint. X-rays of the hips revealed a negative examination; there was no pathology found. The Board acknowledges that on VA fee basis examination in April 2006, the Veteran was diagnosed with bilateral hip bursitis with hyperflexability. However, x-rays taken at that time showed findings within normal limits. In addition, at the April 2006 examination, the Veteran reported that his bilateral hip disability had existed for four years and was not due to injury. The Board further acknowledges that a diagnosis of ligamentous laxity of multiple joints including the hips was rendered during the March 2011 VA examination. However, the examiner noted that further diagnosis was not possible without the studies that were ordered, but not obtained (because the Veteran left the clinic without the studies being done (See March 2011 VA examination addendum)). The RO requested that the Veteran be seen for another examination. They were notified that the request was cancelled because the Veteran hung up the telephone when VA called in May 2012 to inform him that he need to be seen for another examination. While VA has a duty to assist the Veteran in the development of his claim, the Veteran has a duty to cooperate with VA. See Wood v. Derwinski, 1 Vet. App. 190 (1991). The law also provides that a claimant for VA benefits has the responsibility to present and support the claim. 38 U.S.C.A. § 5107(a). Accordingly, the Board finds the May 2010 and August 2012 examination reports (which essentially find no current hip disability) more probative than the April 2006 and March 2011 examinations. The Court has indicated that in the absence of proof of a present disability, there can be no valid claim for service connection; an appellant's belief that he is entitled to some sort of benefit simply because he had a disease or injury while on active service is mistaken, as Congress has specifically limited entitlement to service connection to cases where such incidents have resulted in a disability. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Rabideau v. Derwinski, 2 Vet. App. 141, 143-144 (1992). Even assuming, en arguendo, that the Veteran has a current bilateral hip disability, this appeal must nevertheless be denied because the evidence is against finding that his bilateral hip disorder is related to service or an incident therein. Indeed, STRs show acute hip pain in service; and the Veteran has asserted that he injured his hips in service in Hawaii after being hit by a wave (even though he was not sure whether it was his hip or his back that was injured and he could not remember receiving treatment after the incident). Postservice, he was seen in 1989 with complaints of a back injury that happened at work, and at that time he reported that the pain was located around the right hip area, there was no diagnosis rendered related to the hip. He was examined by VA in 2002 and did not mention that he had a hip disorder. At the April 2006 VA examination he reported that his bilateral hip disability had existed four years prior and was not due to injury. Such evidence does not support findings that a chronic bilateral hip disability was present during service. It appears he did not seek treatment for a hip disorder until 2006, when he was seen at a VA outpatient clinic with complaints of hip pain, which was approximately 20 years postservice. Such a lengthy period without evidence of treatment may be viewed as evidence weighing against the claim. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). Based on the foregoing, service connection for a bilateral hip disability on the basis that it was manifested in service is not warranted. Furthermore, the competent evidence of record does not support a nexus between the Veteran's claimed bilateral hip disability and his military service. VA examiner in August 2012 opined that the Veteran's bilateral hip disability is less likely than not (less than 50 percent probability) incurred in or caused by an in-service injury, event or illness. His rationale for the opinion was that the Veteran's hip examination was normal age senescence without osseous or articular change and that his problem was his low back. The Board finds the August 2012 VA examination report more probative than other VA examinations of record, as it presents a competent medical opinion and rationale informed by review of the pertinent evidence including an examination of the Veteran. That examination report weighs significantly against the claim of entitlement to service connection for a bilateral hip disability; and there are no opinions to the contrary of record. Based on these findings, service connection is not warranted for a bilateral hip disability. The Board recognizes that the Veteran has also claimed that the problem with his hips was caused by his service-connected bilateral ankle disability. Additionally, a claim of service connection secondary to a bilateral knee disability has also been raised. The probative medical evidence in this case establishes that the Veteran's disability of the hips is not secondary to a service-connected disability. The April 2006 examiner opined that it is as least as likely as not that the Veteran's bilateral hip condition is secondary to the bilateral ankle injury. His rationale was that per the March 1986 emergency care and treatment record, the Veteran had a motor bike injury that resulted in a right ankle sprain. There was no other mention of a bilateral hip problem throughout in-service records or post service records from May 2005 to January 2006. The Veteran presented with bilateral hip hyperflexion range of motion and that was most likely the cause of his bilateral hip condition, not the right ankle condition. The April 2006 examiner's opinion clearly weighs against finding that the claimed bilateral hip disability was caused by the service-connected bilateral ankle disability. However, in March 2010 the Board found the April 2006 VA examination inadequate because the examiner did not offer an opinion as to whether the Veteran's bilateral hip disability had been aggravated by the service-connected bilateral ankle disability. Notwithstanding the April 2006 examiner's failure to address whether the claimed bilateral hip disability had been aggravated by a service-connected disability, the Board finds his opinion probative as to whether the claimed bilateral hip disability was proximately due to, or the result of, a service-connected disability; and to that extent, the opinion is adequate. The opinion contains a competent medical opinion addressing the pertinent etiological question with a clear conclusion and analytical rationale. It was informed by direct inspection and interview of the Veteran and acceptance of the Veteran's own details of his symptom experience and history. The Board has reviewed the entirety of the evidence of record and finds that there is no competent evidence of record which contradicts the findings present in the April 2006 examination report. The April 2006 examiner's opinion is clear in finding no relationship between the bilateral hip disability and the service-connected bilateral ankle disability. Further the August 2012 VA examiner opined that the Veteran's bilateral hip disability is less likely than not (less than 50 percent probability) proximately due to or the result of a service-connected disability (refers to the ankle and knee disabilities). He noted that the Veteran's hip examination was normal age senescence without osseous or articular change and that his problem was his low back. As earlier noted, the Board finds the August 2012 examination highly probative in deciding matters regarding this appeal. Consequently, service connection for a bilateral hip disability as secondary to a service-connected disability is not warranted, and the claim on a secondary basis must be denied. The Board recognizes that the Veteran has asserted his belief that his claimed bilateral hip disability occurred secondary to bad gait or stance, posture and workload due to his ankles. Lay statements may be competent to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. §§ 3.303(a), 3.159(a); see Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). See also Robinson v. Shinseki, 312 Fed. Appx. 336 (Fed. Cir. 2009) (non-precedential) (confirming that, 'in some cases, lay evidence will be competent and credible evidence of etiology'). However, a determination concerning the possibility of a causal relationship between a bilateral hip disability and bilateral ankle/knee disability requires specialized training, and may therefore not be established by lay opinions on etiology. Furthermore, the competent medical evidence of record weighs against the Veteran's asserted explanation. On the issue of aggravation of a bilateral hip disability by the service-connected bilateral ankle disability, the matter was addressed in the May 2010 VA examination report. The May 2010 examiner opined that the Veteran's bilateral hip disability was not causally related to military service or a result of or aggravated by his service-connected right and left ankle disabilities. The Board, in December 2010 found the May 2010 VA examination inadequate on the basis that the examiner's opinion was based on an incorrect history since the examiner did not acknowledge or discuss the Veteran's in-service complaints regarding his hips. He underwent another examination in March 2011. The March 2011 examiner diagnosed the Veteran with ligamentous laxity of multiple joints, including the hips. Pursuant to Board remand in July 2012, another examination was conducted. The examiner was asked to respond to the matter of whether the Veteran's claimed bilateral hip disability was aggravated by the service-connected bilateral ankle and or knee disabilities. The evidence shows that the Veteran is service connected for a right ankle disability evaluated as 20 percent disabling from February 1988, a left ankle disability evaluated as 20 percent disabling from September 2003, and right and left knee disabilities each evaluated as 10 percent disabling from September 2005. The Board has reviewed the entirety of the evidence of record and finds that there is no competent/probative evidence of record which supports findings of aggravation of the non-service-connected bilateral hip disability by a service-connected disability. The Board finds that the clear preponderance of the evidence is against any such finding. The Board finds it highly significant that in May 2010 x-rays taken of the hips were negative and examination revealed normal findings of the bilateral hips. On examination August 2012 examination, the Veteran's hips were normal and x-ray findings were negative. The examiner found there was no pathology. Furthermore, the Veteran has not submitted any evidence to support a claim of aggravation. Thus, the preponderance of the evidence in this instance is against a finding that the Veteran's bilateral hip disability is the result of aggravation by his service-connected bilateral ankle/knee disability; and service connection on the basis of aggravation of a non-service connected bilateral hip disability by a service-connected disability is not warranted. The preponderance of the evidence in this case is against finding that the Veteran's claimed bilateral hip disability was manifested in service or otherwise related to service, or secondary to or aggravated by his service-connected right ankle disability or any service-connected disability. There is not such a state of equipoise of the positive evidence with the negative evidence to permit a favorable determination in this case. 38 U.S.C.A. § 5107(b). ORDER Entitlement to service connection for bilateral hip disability, including as secondary to a service-connected disability is not warranted. The appeal is denied. ____________________________________________ ALAN S. PEEVY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs