Citation Nr: 1328978 Decision Date: 09/10/13 Archive Date: 09/17/13 DOCKET NO. 09-35 854 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for a back disability. 2. Entitlement to service connection for sleep apnea. 3. Entitlement to service connection for a left hip disability, to include as secondary to a back disability. REPRESENTATION Appellant represented by: Missouri Veterans Commission ATTORNEY FOR THE BOARD D. Schechner, Counsel INTRODUCTION The appellant is a Veteran who served on active duty for training from September 1967 to January 1968 and on active duty from December 1990 to September 1991, and also served in the Air National Guard (ANG). These matters are before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued by the St. Louis, Missouri RO in May 2008 (which in pertinent part declined to reopen a claim of service connection for sleep apnea) and in July 2009 (which in pertinent part denied service connection for a left hip condition and declined to reopen a claim of service connection for a back disability). In May 2011, the Board reopened and remanded the claims regarding back disability and sleep apnea and also remanded the claim for left hip disability. In April 2013, the Board again remanded the matters for additional development. FINDINGS OF FACT 1. A chronic back disability was not manifested in service; arthritis of the thoracolumbar spine was not manifested in the first year following the Veteran's discharge from active duty; and a back disability is not shown to be related to the Veteran's service. 2. Sleep apnea was not manifested in service; and the preponderance of the evidence is against a finding that such disability is related to the Veteran's active service. 3. A chronic left hip disability was not manifested in service; arthritis of the left hip was not manifested in the first year following the Veteran's discharge from active duty; and the preponderance of the evidence is against a finding that a left hip disability is related to the Veteran's active service or a service-connected disability. CONCLUSIONS OF LAW 1. Service connection for a back disability is not warranted. 38 U.S.C.A. §§ 1110, 1112, 1113, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012). 2. Service connection for sleep apnea is not warranted. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2012). 3. Service connection for a left hip disability is not warranted. 38 U.S.C.A. §§ 1110, 1112, 1113, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice requirements apply to all five elements of a service connection claim: 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. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484-86 (2006), aff'd, 483 F.3d 1311 (Fed. Cir. 2007). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Veteran was advised of VA's duties to notify and assist in the development of the claims prior to their initial adjudication. January 2008 and April 2009 letters explained the evidence necessary to substantiate the claims, the evidence VA was responsible for providing, and the evidence he was responsible for providing. These letters also informed him of disability rating and effective date criteria. He has had ample opportunity to respond/supplement the record and has not alleged that notice in these matters was less than adequate. The Veteran's service treatment records (STRs) are associated with his claims file, and pertinent postservice treatment records have been secured. The RO arranged for VA examinations in July 2011. As will be discussed in greater detail below, the Board finds these examinations to be adequate, as they included a thorough review of the Veteran's medical history, physical examinations noting all pertinent findings, and medical opinions with adequate supporting rationale. See Barr v. Nicholson, 21 Vet. App. 303 (2007). The Veteran has not identified any pertinent evidence that remains outstanding. VA's duty to assist is met. Legal Criteria, Factual Background, and Analysis Initially, the Board notes that it has reviewed all of the evidence in the Veteran's claims file and in Virtual VA (VA's electronic data storage system) with an emphasis on the evidence relevant to this appeal. 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). 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 claims. Service connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). In order to establish service connection for the claimed disorder, there must be (1) evidence of a current disability; (2) evidence of incurrence or aggravation of a disease or injury in service; and (3) evidence of a causal connection between the disease or injury in service and the current disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Disorders diagnosed after discharge may still be service connected if all the evidence establishes that the disorder was incurred in service. 38 C.F.R. § 3.303(d); Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Certain chronic disabilities (including arthritis) may be service-connected on a presumptive basis if manifested in a specified period of time following a veteran's discharge from active duty (one year for arthritis). 38 U.S.C.A. §§ 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. A layperson is generally not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183, 186 (1997). However, lay evidence may be competent evidence to establish incurrence. See Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (e.g., a broken leg), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Competent medical evidence is needed where the determinative question is one requiring medical knowledge. Id. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. It may also mean statements conveying sound medical principles found in medical treatises, and may include statements in authoritative writings, such as medical and scientific articles and research reports. 38 C.F.R. § 3.159(a)(1). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a layperson. 38 C.F.R. § 3.159(a)(2). Disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a) (as in effect before and after October 10, 2006). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease, will be service connected. However, VA will not concede that a non-service-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities and determine the extent of aggravation by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level. 38 C.F.R. § 3.310 (b). Back disability The Veteran claims that he has a chronic back disability that was incurred in service. He asserts that he sustained a back injury loading an airplane while on active duty in about January 1991,. He relates that he was helping to move a load from a forklift he was operating, and the load fell off the end of the forks, causing him to fall as well, hitting his back against the rollers on a C-130 aircraft. He states that he was treated for the injury by an Air Force doctor. He also relates that he fell from the top of a bunk bed injuring his back, also while on active duty in England awaiting transit back to the United States in late May or early June 1991. He states that he self-treated with pain pills, as there was no doctor available. ANG records show that in July 1984 (while on inactive duty training) the Veteran was involved in a motor vehicle accident resulting in pain and multiple contusions to the head, neck, left arm, right shoulder, and right side of the rib cage. Treatment records show he was found to have a closed fracture of the T10 rib on the right side. He was restored to full duty status in late August 1984. A July 1984 Line of Duty Determination found the Veteran to have been in the line of duty at the time of the motor vehicle accident. February 1986 records note severe pain near the paravertebral muscles medial to the right scapula secondary to trauma sustained from a life raft and its carbon dioxide cartridge landing on the Veteran's back; the diagnosis was muscle trauma with spasm. A June 1987 treatment record notes back pain for 3 to 4 weeks, for which the Veteran was taking pain pills off and on. On physical examination, straight leg maneuver caused pain on the left and there was soreness in the left paralumbar area. On September 1992 examination (approximately one year after separation from the last period of active duty) there was no significant medical or surgical history since a previous examination in September 1988; the Veteran endorsed a "normal" spine and denied arthritis, rheumatism, or bursitis; bone, joint or other deformity; or recurrent back pain. A July 1994 record notes the Veteran was on physical profile status after a back injury and hospitalization; there is no indication that he was on active duty at that time. On August 1995 examination, the Veteran reported recurrent back pain for which he was taking muscle relaxers; he reported back aches for 6 to 7 months. On October 1995 examination, the Veteran endorsed a "normal" spine. An April 2000 postservice treatment record notes a complaint of lower back pain. An April 2005 private treatment record notes complaints of left low back pain that "started three months ago without any particular injury or trauma"; the Veteran denied any previous episodes of trauma. A January 2006 private treatment record noted the Veteran complained of left low back pain, left hip pain, and left groin and leg pain. He reported having low back pain intermittently throughout most of his life, though "this pain primarily began for him approximately six months ago." In a March 2009 statement in support of a request to reopen the claim, the Veteran stated that he was on active duty in the late 1980s when he was involved in a "deer avoidance car accident" in which he hit a tree head-on; he stated that he noticed soreness in his back for many years afterward. He stated again that he strained his back in 1991, while on active duty during Operation Desert Storm, when he was assisting in moving a safe; he stated that he strained his back and it "bothered [him] for a couple of weeks". In an April 2009 medical statement from the Veteran's treating physician, Dr. E.F., it was noted that the Veteran underwent surgery (laminectomy and biopsy) in March 2009 for what appeared to be a cyst or tumor of his T8 spinal cord. The lesion was biopsied and found to be "some sort of necrosis"; the operative report includes a diagnosis of T8 intramedullary lesion, considering possible neoplasm. There was also scarring noted in and around the lesion which had distorted the spinal cord. The physician opined, "This represented possible infection from previous injury," and added that the Veteran had post-operative dysesthesia that would improve over the following 2 months. A September 2009 MRI of the thoracic spine showed diffuse degenerative changes of the thoracic spine; hemangioma within the vertebral body of T4; and no focal disc protrusion, extrusion, central canal stenosis, or neural foraminal encroachment. On July 2011 VA examination (pursuant to the Board's May 2011 remand), the Veteran reported having chronic low back pain since about 1991. He had spinal surgery in 2009 to biopsy a cyst on his spine but no other hospitalizations. He had received pain clinic treatment from 2008 through 2010, and had received epidural, muscle block and steroid injections in the past. He reported constant back pain 5/10 in severity with exacerbations to 10/10. He reported moderate flare-ups of low back pain every 2 to 3 weeks lasting for several hours, precipitated by walking or working around the yard, and he reported that it hurt to climb or descend steps in his house. Lumbar spine X-rays showed mild spondylosis throughout the lower thoracic and lumbar spine, and minimal degenerative disc disease at L3-L4 with mild disc space narrowing and degenerative changes of the facet joints at L4-L5 and L5-S1. The diagnosis was minimal degenerative joint disease with mild spondylosis of the lower thoracic and lumbar spine. The examiner opined that the disability was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that the Veteran has degenerative arthritis in his spine, his left hip was replaced due to severe degeneration, and he also has degeneration in his right hip; the examiner also noted a May 2005 doctor's note stating that the Veteran began having low back pain 3 months earlier without any particular injury or trauma. The examiner further stated that as we age and gain weight (noting that the Veteran has a longstanding history of obesity and morbid obesity), we put added stress on the spine and spinal muscles, causing pain; the examiner opined that the Veteran's weight is a major contributing factor to his back pain, noting that according to the medical record the Veteran had a history of weight problems at least as early as February 1977 and was in an ANG Weight Control Program. The Veteran submitted VA and private treatment records through 2013 showing findings similar to those on the VA examination outlined above. The records show ongoing treatment for several diagnosed back problems, including lumbar radiculopathy, syringomyelia, and myofascial disease, with no opinions regarding etiology. He has also submitted "buddy statements" corroborating the incidents that allegedly caused a back disability, including an injury sustained helping to move a large safe during the first week stationed in the United Arab Emirates and an injury sustained falling from the top bunk of a bunk bed in England on a return trip from Saudi Arabia; and lay statements of his own as well. Notably, the Board's May 2011 remand instructed the RO to obtain records of the alleged service treatment in January 1991. A December 2012 response to the RO's request for records from the Veteran's unit from January through September 1991 states that the allegation was investigated and no results were found. A January 2013 memorandum includes a formal finding of unavailability of the Veteran's complete service treatment records and clinical records from treatment while on active duty in January 1991. The Board finds that the July 2011 VA examiner's opinion is entitled to great probative weight, as it reflects a thorough review of the Veteran's complete medical history and statements included in the claims file and includes a detailed explanation of rationale, with citation to factual evidence, and identifying alternate etiological factors for the Veteran's back disability, including aging and obesity. A chronic back disability was not diagnosed in service or postservice until approximately 2005, or 14 years after the Veteran's separation from his last period of active duty service. While he has reported (including on July 2011 VA examination) that he has had continuous back problems since an injury in service, and in some medical records he has attributed his current back complaints to such injury, his accounts have been inconsistent and self-serving, and are deemed not credible. Where contemporaneous records would be expected to provide support for the Veteran's accounts, they do not. The Board finds significant that a year after his separation from his last period of active duty service in 1991, the Veteran reported having a "normal" spine and denied any recurrent back pain or symptoms. Accordingly, service connection for a back disability on the basis that such disability became manifest in service, and persisted, is not warranted. Inasmuch as there is no evidence that arthritis of the spine was manifested in the first year following the Veteran's separation from active duty, service connection for such disability on a presumptive basis (as a chronic disease under 38 U.S.C.A. §§ 1112) likewise is not warranted. The Board finds further that the preponderance of the evidence is against the Veteran's claim seeking service connection for a back disability. His STRs are silent regarding any chronic back disability. The only medical evidence that directly addresses the matter of a nexus between the Veteran's current back disability and his service/injury(ies) therein, with adequate supporting rationale, is the report of the July 2011 VA examination, when the examiner opined that the Veteran's back complaints are unrelated to his service or any injury therein n. The physician noted the history of the claimed and diagnosed disabilities and thoroughly explained the rationale for the opinion. The Board finds this evidence highly probative in the matter at hand (as the examiner is a medical professional qualified to provide it and supports it with explanation of rationale and citation to supporting factual data). Because there is no competent (medical opinion/treatise) evidence to the contrary, the Board finds the July 2011 VA examiner's opinion to be persuasive. The Board notes the lay "buddy" statements submitted on the Veteran's behalf. They may reasonably be conceded to be credible evidence supporting that he sustained acute back injuries. However, they are not material regarding a nexus between the injuries in service and the Veteran's current back disability. Furthermore, in the absence of credible evidence of continuity of symptoms, the Veteran's own assertions that there is a nexus between his current back disability and an injury or injuries in service are not competent evidence. The etiology of an insidious process such as arthritis is a matter beyond the capability of lay observation, but is a complex medical question that requires medical knowledge/training. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). The Veteran is a layperson, and lacks the training/expertise to offer a probative opinion in the matter; he does not cite to supporting medical opinion or treatise evidence, and does not provide any adequate explanation of rationale for his theory or entitlement (other than the allegation of continuity of symptoms, which the Board has found not credible). In light of the foregoing, the Board concludes that the preponderance of the evidence is against the Veteran's claim of service connection for a back disability. Accordingly, the appeal in the matter must be denied. Sleep apnea The Veteran contends that he has a current sleep apnea disability that was incurred in service. He contends that his sleep apnea began after he returned home from his active duty period in Saudi Arabia in 1991. He has stated that he was next sent to Offutt Air Force Base, where he first experienced symptoms and allegedly complained to the doctor there of trouble with sleep apnea many times before finally being diagnosed in 1995. He has stated that he was discharged from the National Guard because of his sleep apnea because he could no longer be mobilized or moved into a different job. The STRs are silent for any complaints, findings, treatment, or diagnosis regarding sleep problems. A September 1992 examination included a pulmonary function questionnaire in which the Veteran denied any breathing difficulties, including feeling "abnormally sleepy most of the time". The medical record reflects that the Veteran first received a diagnosis of obstructive sleep apnea (OSA) in September 1995 (not during a period of active duty). An August 1995 examination noted that his complaint of problems sleeping since March 1991, including waking up frequently, problems with snoring, reported apneic episodes, and daytime sleepiness. An April 1997 private treatment record notes an impression of severe OSA improved with C-Pap machine, following an uvulopalatopharyngoplasty. The record notes that a previous sleep study in September 1995 was consistent with severe OSA. A July 1997 medical statement-letter indicates the Veteran was status post uvulopalatopharyngoplasty and continued to have some OSA. An August 1997 Medical Board Report recommended medical disqualification from continued Air National Guard service due to severe OSA, with approximate date of origin of September 1995, found to have existed prior to service but not permanently aggravated by service. An April 2000 postservice treatment record, among other records, noted sleep apnea. On July 2011 VA examination (pursuant to the Board's May 2011 remand), the Veteran reported that he had snoring problems and was told he stopped breathing at night. He reported having trouble staying awake at work. He stated that sleep apnea was diagnosed at Offutt Air Force Base in approximately 1995, at which time he was referred for a sleep study and started on CPAP treatment. He reported that he is now much improved and not as tired during the day. It was noted that he underwent an uvulopalatopharyngoplasty in 1997. On physical examination, pulmonary exam found no abnormal breath sounds; the examiner cited to results of an April 1997 sleep study diagnosing sleep apnea. The diagnosis was severe OSA; the examiner opined that it was less likely than not (less than a 50 % probability) incurred in or caused by service. The examiner explained that physician who provided the initial diagnosis felt that the Veteran's sleep apnea was due to his being severely overweight (337 pounds)( which was consistent with medical literature [indicating that obesity was an etiological factor for OSA]). The examiner cited to the medical record which showed, the Veteran had a history of weight problems as early as in February 1977 and was in an ANG Weight Control Program. The evidence includes additional VA and private medical records through 2013 noting continuing sleep apnea and updated sleep studies, with no opinions offered regarding etiology; buddy statements in support of the contention that his sleep apnea began during active duty service in 1991; and statements from the Veteran indicating that his colleagues in Operation Desert Storm "told him that he snored loudly and stopped breathing occasionally." The Board finds that the July 2011 VA examiner's opinion is entitled to great probative weight, as it reflects a complete review of the Veteran's complete medical history and statements included in the claims file and includes a detailed explanation of rationale. Sleep apnea was not diagnosed in service or postservice until approximately 1995, or 4 years after the Veteran's separation from his last period of active duty service. While he has reported that he has had continuous sleep problems since service, his accounts have been inconsistent and are self-serving. Furthermore, where contemporaneous records would be expected to provide support for the accounts, they do not. Consequently, the Board finds his reports of sleep apnea symptoms existing ever since to not be credible. The Veteran has not reported (upon VA requests to identify any such treatment) seeking sleep apnea treatment postservice prior to 1995. Regarding the "buddy" lay statements attesting that the Veteran had sleep apnea on active duty in Southwest Asia, the Board notes initially that rather than constituting independent corroborating evidence of the Veteran's accounts, the identical wording and form of the statements suggest they were prepared and presented [by the Veteran] to the signers for endorsement. The Board does accept the statements as corroboration that the Veteran snored in service. However, whether or not the snoring was a symptom of OSA is a medical question. The diagnosis of OSA is not one that can be made by lay observation; it requires medical expertise/diagnostic studies. No medical provider has opined that complaints of snoring in service (and double-digit intervals of breaths between snores) of themselves support a diagnosis of sleep apnea on active duty. See Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009. Consequently, service connection for sleep apnea on the basis that such disability became manifest in service, and persisted, is not warranted. The Board finds further that the preponderance of the evidence is against the Veteran's claim seeking service connection for sleep apnea. The STRs are silent regarding any sleep disability. The only medical evidence that directly addresses the matter of a nexus between the Veteran's current sleep apnea and his service/injury therein, with adequate supporting rationale, is the report of the July 2011 VA examination, when the examiner opined that the Veteran's OSA complaints are unrelated to his service or any injury therein. The physician noted the history of the claimed and diagnosed disability and thoroughly explained the rationale for the opinion, identifying alternate, nonservice-related, etiological factors present. The Board finds this evidence highly probative in the matter at hand (as the examiner is a medical professional qualified to provide it and supports it with explanation of rationale and citation to supporting factual data). Because there is no competent (medical opinion/treatise) evidence to the contrary, the Board finds the July 2011 VA examiner's opinion to be persuasive. In the absence of credible evidence of continuity of symptoms, the Veteran's own assertions that there is a nexus between his current sleep apnea and service are not competent evidence. The etiology of a pulmonary/respiratory process such as OSA is a matter beyond the capability of lay observation, but is a complex medical question that requires medical knowledge/training. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). The Veteran is a layperson, and lacks the training/expertise to offer a probative opinion in the matter; he does not cite to supporting medical opinion or treatise evidence, and does not provide any adequate explanation of rationale for his theory or entitlement (other than the allegation of continuity of symptoms, which the Board has found not credible). In light of the foregoing, the Board concludes that the preponderance of the evidence is against the Veteran's claim of service connection for sleep apnea. Accordingly, the appeal in the matter must be denied. Left hip disability The Veteran's theory of entitlement as to the claim of service connection for a left hip disability is primarily one of secondary service connection. He contends that he began having left hip problems associated with his back problems and that a left hip disability developed secondary to his back disability (which is not service connected, and for which service connection is denied herein). Service connection has been established for tinnitus, rated 10 percent; and bilateral hearing loss, rated 0 percent. As the Veteran has also advanced a contention that the left hip disability may have begun during service and persisted, the Board will also address a direct (i.e., to service) causation theory of entitlement to service connection. The Veteran's STRs are silent for any complaints, treatment, or diagnosis regarding the left hip. On a September 1992 examination (approximately one year after separation from the last period of active duty), the Veteran endorsed "normal" lower extremities and denied any arthritis, rheumatism, or bursitis, or any bone, joint or other deformity. On October 1995 examination, the Veteran again endorsed "normal" lower extremities. An October 1996 record notes the Veteran was placed on physical profile for "strain ligaments, muscles of lower extremities", specified in a separate medical note as "acute adductor muscle strain left leg". On December 2003 private treatment record, in a review of musculoskeletal symptoms, the Veteran complained of [unspecified] myalgia but denied any claudication, decreased range of motion, fasciculations, joint pain, joint redness, joint stiffness, joint swelling, muscle atrophy, muscle cramps or muscle weakness; physical examination results found full range of motion in all joints, and all joints and muscles were found to be normal. A January 2006 private treatment record notes the Veteran's complaint of left hip pain. X-rays revealed a normal appearance of the left sacroiliac joint, and also showed mild degenerative narrowing of the left hip joint space with minimally more prominent narrowing on the left compared to the right hip; no active skeletal process was identified, there was no evidence of a recent fracture in the left pelvis or proximal left femur, and no evidence of avascular necrosis of the femoral head. A later January 2006 private treatment record notes the Veteran complained of left low back pain, left hip pain, and left groin and leg pain. He reported having low back pain intermittently throughout most of his life, though "this pain primarily began for him approximately six months ago." He had difficulty going from a sitting position to a standing position secondary to left hip pain; he had limited range of motion, with flexion and extension approximately 45 degrees and 10 degrees, respectively, secondary to the pain. Range of motion of the left hip was normal, though the hip was tender to palpation over the left bursa. The physician noted that the Veteran's weight was a significant contributing factor to his back and left hip pain. A February 2006 X-ray of the left hip showed the tip of a needle projecting over the inferior aspect of the left sacroiliac joint. Private treatment records from February through May 2006 show that the Veteran received left sided sacroiliac joint injections and a left greater trochanteric bursa injection for pain relief. On June 2007 private treatment record, the Veteran complained of pain in his left buttock that radiated in his left groin, and across his back and his left lateral thigh. X-ray results showed early osteoarthritic change with joint space narrowing and spurring involving the left hip. The impressions following physical examination included possible left sacroiliac inflammation and possible left hip joint-mediated pain. On February 2010 private treatment record, the impression was of left hip pain. On March 2010 private treatment record, MRI results indicated moderate to severe degenerative changes of the left hip with small amount of joint effusions noted in the left hip; the impression was of severe osteoarthritis of the left hip joint. On April 2010 private treatment record, the impression was of left hip joint pain, for which he was administered a joint injection and arthrography. On April 2010 private treatment record, the Veteran denied any aching muscles or joints and any weakness or stiffness of joints. On July 2011 VA examination, the Veteran reported that he began having left hip pain 5 years earlier, describing it as intermittent for about one year. He reported that he began seeing a physician at the North Kansas City hospital pain clinic and was told he had degeneration in both hips; he underwent a left total hip replacement in June 2011 and reported that the pain was now gone. He reported symptoms including pain and stiffness of the left hip. X-rays of the left hip showed status post total left hip arthroplasty with no acute bony abnormality identified. The diagnosis was status post left hip replacement; the examiner opined that it was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that the Veteran had no injury to the hip on active duty and no reports of chronic hip pain on active duty; that the left hip was replaced due to severe degeneration; and the Veteran also has degeneration in his other (right) hip and his spine; the examiner opined that that is the only connection to be found between the Veteran's spine and hip. The Veteran has also submitted VA and private treatment records through 2013 showing findings similar to those on the VA examination outlined above. It is not shown that a left hip disability became manifest in service and persisted, or that arthritis of the left hip was manifested in the first postservice year. The Veteran's STRs do not contain any evidence of complaint, finding, treatment or diagnosis regarding the left hip. There is also no evidence of postservice continuity of left hip complaints; by the Veteran's own accounts, such complaints began in approximately 2006, many years after separation from service. Postservice evaluation/treatment records provide no indication that any left hip disability may somehow be directly related to the Veteran's service. Accordingly, service connection for a left hip disability on the basis that such was incurred or aggravated in service, or on a presumptive basis (for arthritis of the hip as a chronic disease under 38 U.S.C.A. § 1112), is not warranted. Any reports of longer-existing left hip complaints or symptoms are inconsistent with, and contradicted by, the Veteran's own accounts regarding the onset of such problems on examination, and are clearly compensation-driven; therefore any such reports made more recently lack probative value. The Veteran's asserted secondary service connection theory of entitlement lacks legal merit. As was noted above, he contends that his left hip disability was caused or aggravated by a back disability. As a back disability is not service-connected, this theory of entitlement does not meet a threshold requirement for substantiating a secondary service connection claim, i.e., an already service connected disability to which the left hip disability at issue can be related. See 38 C.F.R. § 3.310. [The disabilities for which service-connection has been established, hearing loss and tinnitus, clearly are not such that would cause or aggravate a left hip disability.] In light of the foregoing, the Board concludes that the preponderance of the evidence is against the Veteran's claim of service connection for a left hip disability. Accordingly, his appeal in the matter must be denied. ORDER Service connection for a back disability is denied. Service connection for sleep apnea is denied. Service connection for a left hip disability, to include as secondary to a back disability, is denied. ____________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs