Citation Nr: 1335543 Decision Date: 11/04/13 Archive Date: 11/13/13 DOCKET NO. 08-35 663 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUE Entitlement to service connection for a bilateral hip disorder. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL The appellant ATTORNEY FOR THE BOARD K. Osegueda, Associate Counsel INTRODUCTION The appellant had active service from September 7, 1977 to October 11, 1977. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from a February 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. In that rating decision, the RO denied the appellant's application to claims for service connection for right and left hip disorders because new and material evidence had not been submitted. In March 2012, the appellant testified at hearing before a Veterans Law Judge at the RO. A transcript of that hearing has been associated with the record. During the hearing, the Veteran submitted additional evidence with a waiver of initial agency of original jurisdiction (AOJ) consideration. See 38 C.F.R. § 20.1304 (2012). In June 2012, the Board reopened the claim of service connection for a bilateral hip disorder, and remanded the issue for further development. After completing the requested development, the Appeals Management Center (AMC) denied the claim (as reflected in a December 2012 supplemental statement of the case (SSOC)) and returned the case to the Board for appellate review. In addition to the paper claims file, there are Virtual VA and Veterans Benefits Management System (VBMS) paperless files associated with the Veteran's claims. A review of the documents in the paperless claims files reveals documents that are either duplicative of the evidence in the paper claims file or irrelevant to the issue on appeal. As noted in the June 2012 remand, the appellant has pending applications to reopen claims for service connection for the residuals of poliomyelitis (polio) and a low back disorder, claims for service connection for the residuals of strokes and prostate cancer, a claim for special monthly compensation based on the need for aid and attendance of another or by reason of being housebound, and a claim for a total disability rating based on individual unemployability due to a service-connected disability. As these matters have not yet been adjudicated by the RO, the Board does not have jurisdiction over them, and they are referred to the RO for initial consideration. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. There is clear and unmistakable evidence the appellant's bilateral hip disorder preexisted his service. 2. The Veteran has not been shown by competent medical evidence to currently have a bilateral hip disorder that is related to any aggravation during service of his preexisting disorder or otherwise etiologically related to his military service. CONCLUSION OF LAW A bilateral hip disorder was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1111, 1153, 1154, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.306 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Upon receipt of a substantially complete application for benefits, VA must notify the claimant of what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and, (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103(a); 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that, upon receipt of an application for a service connection claim, 38 U.S.C. § 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, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. The RO provided the appellant with a notification letter in November 2006, prior to the initial decision on the claim in February 2007. Therefore, the timing requirement of the notice as set forth in Pelegrini has been met and to decide the appeal would not be prejudicial to the claimant. Moreover, the requirements with respect to the content of the notice were met in this case. The letter informed the appellant of the information and evidence needed to substantiate his claim for service connection and notified him of the division of responsibilities in obtaining such evidence. The letter also explained how a disability rating is determined for a service-connected disorder and the basis for determining an effective date upon the grant of any benefit sought, in compliance with Dingess, 19 Vet. App. at 490-491. In addition, the duty to assist the appellant has also been satisfied in this case. The appellant's service treatment records, as well as all identified and available post-service medical records and Social Security Administration (SSA) records, are in the claims file and were reviewed by both the RO and the Board in connection with the claim. The appellant has not identified any other outstanding records that are pertinent to the issue being decided herein. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, the appellant was afforded a VA joints examination in January 2009 and a VA hips examination in September 2012, pursuant to the June 2012 remand. Additionally, the September 2012 examiner provided an addendum opinion. Specifically, in the June 2012 remand, the Board directed the examiner to provide opinions as to whether there was clear and unmistakable evidence that the appellant had any defects, infirmities, or disorders of the hips at the time of his entrance into service; whether there was a permanent worsening of any preexisting condition during the appellant's service; whether there was clear and unmistakable evidence that any worsening was due to the natural progress of that condition; and if there was no preexisting disability of the hips prior to the appellant's entrance into service, whether it was at least as likely as not that any such condition had its onset during service, or was otherwise caused by any incident or event that occurred during service. The Board finds that the medical opinions obtained in this case are adequate, as they are predicated on a full reading of the available service treatment records contained in the Veteran's claims file. They consider all of the pertinent evidence of record and provide a complete rationale for the opinions stated. Additionally, the September 2012 VA examiner was fully responsive to the June 2012 remand directives and provided the requested opinions in his addendum opinion. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issue on appeal has been met. 38 C.F.R. § 3.159(c)(4). Additionally, as previously noted, the Veteran was provided the opportunity to testify at a hearing before the undersigned Veterans Law Judge in March 2012. The undersigned Veterans Law Judge clearly set forth the issue to be discussed, and the hearing focused on the elements necessary to substantiate the claim. Questions were asked regarding the Veteran's symptoms before service, during service, and the progression of the disorder since service. The undersigned Veterans Law Judge also inquired as to whether the Veteran was receiving any current treatment in order to determine whether there was any outstanding evidence and asked whether the Veteran had spoken to any doctors about the cause of his current disorder in order to determine whether there may be a medical opinion that could be obtained from a treatment provider. The Veteran indicated that he had not talked to a physician about the etiology of the disorder, to include whether any preexisting bilateral hip disorder was aggravated during service, which is part of the reason the case was remanded to obtain a VA medical opinion. For these reasons, the Board finds that VA fully complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010). VA has further assisted the appellant and his representative throughout the course of this appeal by providing them with a statement of the case (SOC) and SSOCs which informed them of the laws and regulations relevant to the appellant's claim. The appellant has not made the RO or the Board aware of any additional evidence that needs to be obtained in order to fairly decide the particular claim on appeal. He has been given ample opportunity to present evidence and argument in support of his claim. For these reasons, the Board concludes that VA has fulfilled the duty to assist the appellant in this case. Hence, there is no error or issue that precludes the Board from addressing the merits of this appeal. Laws and Regulations Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. 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). The term "chronic disease," whether as manifest during service or manifest to a compensable degree within a presumptive window following service, applies only to those disabilities listed in 38 U.S.C.A. § 1101 and 38 C.F.R. § 3.309(a). Walker v. Shinseki, No. 2011-7184, slip op. at 13 (U.S. Fed. Cir. Feb. 21, 2013). The Board notes that 38 C.F.R. § 3.303(b), applies to only those chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). With respect to the current appeal, this list includes arthritis. See 38 C.F.R. § 3.309(a). In addition, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including arthritis, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307(a), 3.309(a). However, in order for the presumption to apply, the evidence must indicate that the disability became manifest to a compensable degree within one year of separation from service. See 38 C.F.R. § 3.307. In order to establish entitlement to service connection for a disability, the appellant must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. § 1111. History provided by the veteran of the preservice existence of conditions recorded at the time of the entrance examination does not, in itself, constitute a notation of a preexisting condition. 38 C.F.R. §§ 3.304(b)(1); Paulson v. Brown, 7 Vet. App. 466, 470 (1995); Crowe v. Brown, 7 Vet. App. 238, 246 (1995). To rebut the presumption of sound condition under section 1111 of the statute for disorders not noted on the entrance or enlistment examination, VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. VAOPGCPREC 3-2003 (July 16, 2003). Clear and unmistakable evidence is a more formidable evidentiary burden than the preponderance of the evidence standard. See Vanerson v. West, 12 Vet. App. 254, 258 (1999) (noting that "clear and convincing" burden of proof, while a higher standard than a preponderance of the evidence, is a lower burden to satisfy than clear and unmistakable evidence). It is an "onerous" evidentiary standard, requiring that the no-aggravation result be "undebatable." Cotant v. West, 17 Vet. App. 116, 131 (2003) (citing Laposky v. Brown, 4 Vet. App. 331, 334 (1993) (citing Akins v. Derwinski, 1 Vet. App. 228, 232 (1991)) and Vanerson, 12 Vet. App. at 258, 261; id. at 263 (Nebeker, C.J., concurring in part and dissenting in part). Concerning clear and unmistakable evidence that the disease or injury was not aggravated by service, the second step necessary to rebut the presumption of soundness, a lack of aggravation may be shown by establishing that there was no increase in disability during service or that any increase in disability was due to the natural progress of the preexisting condition. Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); 38 U.S.C.A. § 1153. A presumption is an assumption of fact resulting from a rule of law which requires such fact to be assumed from another fact or group of facts found or otherwise established in the action. Black's Law Dictionary 1067 (5th ed. 1979). Therefore, where the presumption of sound condition at entrance to service cannot be rebutted, the fact for which the presumption stands--that is, that the veteran was in sound condition at entry to service as to the disability for which he seeks service connection--must be assumed as a matter of law. To rebut the presumption of sound condition for disorders not noted on the entrance or enlistment examination, VA's General Counsel has clarified that VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. The claimant is not required to show that the disease or injury increased in severity during service before VA's duty under the second prong of this rebuttal standard attaches. This holding replaced the previous standard under 38 C.F.R. § 3.304(b), which had required that if a condition was not noted at entry, but was shown by clear and unmistakable evidence to have existed prior to entry, the burden then shifted to the claimant to show that the condition increased in severity during service. VAOPGCPREC 3-2003. The Court and Federal Circuit Court have adopted the General Counsel's position. Quirin v. Shinseki, 22 Vet. App. 390, 396 (2009); Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). For veterans who served during a period of war or after December 31, 1946, clear and unmistakable evidence is required to rebut the presumption of aggravation where the preservice disability underwent an increase in severity during service, and clear and unmistakable evidence includes medical facts and principles which may be considered to determine whether the increase is due to the natural progress of the condition. 38 C.F.R. § 3.306(b). The government may show a lack of aggravation by establishing by clear and unmistakable evidence that there was no increase in disability during service or that any increase in disability was due to the natural progress of the preexisting condition. 38 U.S.C.A. § 1153 (West 2002); 38 C.F.R. § 3.306 (2012). See also Wagner, 370 F.3d at 1096 (indicating that, in cases where the presumption of soundness cannot be rebutted, the effect is that claims for service connection based on aggravation are converted into claims for service connection based on service incurrence). If this burden is met, then the veteran is not entitled to service-connected benefits. However, if the government fails to rebut the presumption of soundness under Section 1111 by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service, the veteran's claim is one of service connection on a direct incurrence basis. Wagner, 370 F.3d at 1096. Temporary or intermittent flare-ups of symptoms of a preexisting condition, alone, do not constitute sufficient evidence for a non-combat veteran to show increased disability for the purposes of determinations of service connection based on aggravation under section 1153 unless the underlying condition worsened. Davis v. Principi, 276 F. 3d 1341, 1346-47 (Fed. Cir. 2002); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). The law provides that an increase in disability must consist of worsening of the enduring disability. Davis v. Principi, 276 F.3d 1341, 1344 (Fed. Cir. 2002). Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306; Falzone v. Brown, 8 Vet. App. 398, 402 (1995). See also Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002) (which holds that evidence of a temporary flare-up, without more, does not satisfy the level of proof required of a non-combat veteran to establish an increase in disability). A "lasting worsening of the condition"- that is, a worsening that existed not only at the time of separation but one that still exists currently is required. See Routen v. Brown, 10 Vet. App. 183, 189 n. 2 (1997); see also Verdon v. Brown, 8 Vet. App. 529, 538 (1996). Evidence of a prolonged period without medical complaint can be considered, along with other factors concerning the veteran's health and medical treatment during and after military service, as evidence of whether a preexisting condition was aggravated by military service. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). 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 C.F.R. § 3.306(b). The usual effects of medical and surgical treatment in service, having the effect of ameliorating disease or other conditions incurred before enlistment, will not be considered service connected unless the disease or injury is otherwise aggravated by service. 38 C.F.R. § 3.306(b)(1). Independent medical evidence is needed to support a finding that the preexisting disorder increased in severity in service beyond its natural progression. See Paulson v. Brown, 7 Vet. App. 466, 470-471 (1995); Crowe v. Brown, 7 Vet. App. 238, 246 (1994). Factual Background The appellant contends that he has a current bilateral hip disorder resulting from a preexisting disorder that was aggravated by service. Specifically, he reported that he had a current bilateral hip disorder caused by childhood polio that was aggravated during service. See June 2007, February 2008, November 2008, and June 2010 statements. However, in March 2008 and March 2012 statements, the appellant contended that he was diagnosed with polio in his right leg during service. Similarly, in May 2011 and August 2011 statements, he reported that he was not aware that he had polio until after he enlisted. In an August 1977 entrance examination, the examining medical officer reported that the appellant had normal lower extremities. No defects or diagnoses were noted on examination. He reported that the appellant was qualified for enlistment. In an August 1977 enlistment report of medical history, the appellant denied a history of arthritis, rheumatism, or bursitis; and bone, joint, or other deformity. A September 17, 1977 sick call slip documented the appellant's complaint that he had a right leg "lockage." He was relieved from training and referred for an orthopedic evaluation. An orthopedic consultation request, erroneously dated on July 17, 1977, indicated that the Veteran had gross atrophy and shortening of the right leg. In a September 19, 1977 orthopedic treatment note, the appellant complained that his right hip was "locking up" during the first week of basic combat training. He stated that, since the fifth grade, he had known that his right leg was shorter and atrophic. He indicated that he was previously evaluated by a physician for his short leg and the "locking up" of his right hip. He related that no diagnosis was provided, but he was advised to have a build-up of his right shoe. He reported that he was having pain in the right hip and buttocks area from the activities of basic combat training. He denied any recent significant changes in his right lower extremity. He also denied a history of polio or hip disease. On physical examination, the appellant had a lumbar curve to the right, secondary to a short right lower extremity. There was no Trendelenberg sign in either hip. Range of motion of the hips was essentially normal, bilaterally. His right lower extremity was 2 1/2 inches shorter than the left. There was approximately 2 inches of circumferential atrophy of the entire right lower extremity. Motor strength was essentially normal. Deep tendon reflexes were within normal limits. There was no dorsiflexion possible in the right ankle. X-rays of the hips showed inadequate acetabula bilaterally, worse in the right than the left, with coxa magna and subluxation of the hip, more apparent on the right than on the left. The diagnoses were: (1) loss of ankle dorsiflexion; (2) atrophic right lower extremity; (3) subluxation of both hips; and (4) probable old polio. The examining medical officer determined that the appellant was unfit for military duty. In a DA Form 3349, Medical Condition Physical Profile Record, dated on September 19, 1977, the examining medical officer noted that due to subluxation of both hips, loss of ankle dorsiflexion, and lower extremity atrophy, the appellant was undergoing a Medical Evaluation Board and he was to have no duty for training purposes. His conditions were considered "temporary" and not expected to exceed 90 days. He was medically qualified for duty with limitations. The limitations were for 30 days and were to be automatically cancelled on October 22, 1977. A September 19, 1977 report of Medical Evaluation Board proceedings reflected that the appellant had 14 days of active service, including 8 days at the reception station and 6 days of basic training. The Medical Evaluation Board noted that the appellant had subluxation of both hips and an atrophic right lower extremity. The conditions were reported to have existed prior to service, with an approximate date of origin of 1965. The Medical Evaluation Board determined that the conditions were not caused by any incident of service and they were not aggravated during active duty. In a separation examination report, dated on September 19, 1977, the examining medical officer noted an abnormal lower extremities evaluation. Specifically, he indicated that the appellant had loss of ankle dorsiflexion, an atrophic right lower extremity, subluxation of both hips, and probable old polio. He reported that the appellant was not qualified for retention. In an April 1992 SSA disability evaluation, the examining physician noted that the appellant had a history of polio in childhood, residual weakness of the right lower extremity, and complaints of bilateral hip joint pain. The right leg was shorter and smaller in size than the left leg. The appellant indicated that he started having bilateral hip joint pain in the past five years. He reported that he was previously evaluated by multiple specialists and was told that he had severe arthritis in both hip joints. He stated that he previously denied recommendations for artificial replacement of both hip joints. On examination, the appellant complained of pain in both hip joint movements. He walked with a limp because of the unequal lower extremity size and he limped toward the right side. The diagnoses included polio during childhood with residual changes in the right lower extremity, and bilateral hip joint pains secondary to degenerative joint disease. In an April 1992 private treatment note, included in the appellant's SSA medical records, the appellant complained of residuals from polio and arthritis. The examiner noted that the appellant's right leg was shorter with atrophy. A May 1992 SSA x-ray study of the pelvis and bilateral hips showed acetabular abnormalities, consistent with congenital anomaly or previous trauma. The acetabulae were rotated and shallow with supra-acetabular bony buttressing noted on the left. The femoral heads were slightly flattened. The radiologist's impression was probable congenital anomalies in both hips. A June 1992 SSA determination showed the appellant's primary diagnosis was status-post polio. In a June 2000 private treatment note, the appellant reported a medical history significant for polio, which affected his right side. He indicated that he had pain in both of his hips for years. He stated that his left hip pain was more severe than his right hip pain. X-rays showed obvious acetabular dysplasia in the left hip with a high riding humeral head and osteophyte that came off the acetabulum to make a shelf for his acetabulum. The right side showed degeneration or a genetically malformed femoral head with a better acetabulum. The diagnosis was traumatic arthritis of the left hip. The physician noted that he discussed treatment options with the appellant, including a left total hip arthroplasty. In August 2000, the appellant had a total left hip arthroplasty. In the private operative report, the surgeon noted that the appellant's pre- and post- operative diagnosis was acetabular dysplasia of the left hip with degenerative arthritis. He indicated that the appellant had acetabular dysplasia on the left since birth, and he had persistent pain and dysfunction in the left hip. He also noted that the appellant had polio in the right leg, he had less muscle strength in the left leg, and he had a shorter right leg even with a high riding femur on the left. An August 2000 private laboratory report indicated that left hip bone and tissue had features grossly consistent with degenerative joint disease. An August 2000 private x-ray study of the pelvis showed no immediate post surgical complications following a left total hip arthoplasty. Acetabular and femoral components were in good position and there was no loosening or infection. An August 2000 private x-ray study of the pelvis was conducted to evaluate the appellant's left hip prosthesis. The x-rays showed the prosthesis was stable and unchanged from the previous postoperative radiological study. Chronic changes related to right acetabular dysplasia were noted; specifically, the appellant had significant right acetabular dysplasia and associated flattening of the right femoral head. An August 2000 private x-ray study of the pelvis and left hip showed the orientation of the acetabular portion of the left hip prosthesis suggested rotation that may have been due to dysplasia. Dysplastic changes of the right femoral head and acetabulum were also noted. In an October 2001 private radiology report, the interpreter noted that an x-ray study of the abdomen showed that there may have been some deformity of the right proximal femur. In a September 2006 VA treatment note, the appellant complained of pain to the right hip. He reported that he had his left hip replaced in 2001 and that he needed a right hip replacement. He indicated that he had a history of polio to the right side. During a September 2006 VA history and physical, the appellant complained of right hip pain due to osteoarthritis, which was previously diagnosed by a private physician. He indicated that he had a total hip replacement of his left hip by a private surgeon in 2001. He stated that his right hip continued to be very painful despite multiple pain medications, including opiates and anti inflammatory drugs. He reported that he had polio as a child which left him with muscle wasting and weakness in the right lower extremity. He also had unequal leg lengths and a shoe lift for the right leg. On examination, the physician noted that the appellant had obvious muscle wasting in the entire right lower extremity. The right hip joint had some possible anterior swelling versus slight deformity in the area, but it was nontender and had no obvious redness or warmth. Range of motion in the right hip was good as far as flexion, but had rather limited external rotation. The left hip had good range of motion. Motor activity was moderately decreased in the right lower extremity with the most significant weakness being in dorsiflexion of the right foot. Sensation to light touch was intact in the right lower extremity, but the appellant described some paresthesias with touch throughout that leg. Deep tendon reflexes were 2+ at the knees and 0 at the ankle bilaterally. He ambulated with a mild to moderate length. The left lower extremity appeared to have good motor strength and muscle mass. The diagnoses included degenerative joint disease of the hips, status total hip replacement of the left hip in 2001; unequal leg lengths by history; and a history of polio with chronic muscle wasting in the right lower extremity. A September 2006 VA x-ray study of the hips showed moderate degenerative joint disease in the right hip and a prosthesis on the left hip. In a September 2006 VA orthopedic consultation note, the examining physician noted that the appellant had moderate right hip degenerative joint disease that was being managed nonoperatively at that time. The physician related that a total hip replacement would not be considered until the appellant was 55 years old, had no substance abuse for at least one year, and had a stable housing situation. In a November 2006 VA treatment note, the examining physician reported that the appellant had a leg length discrepancy of 1 inch and a 3/4 inch build-up of the right shoe was ordered. In a January 2007 private emergency room note, the appellant reported that he had chronic pain in his left hip. He did not have any complaints pertaining to his right hip. The examiner noted that the appellant needed a right hip replacement. In March 2008, private treatment notes show that the appellant presented to the emergency room with complaints of increased left hip pain. X-rays showed a dislocated left hip prosthesis. In March 2008, the appellant underwent a revision of the left hip total arthroplasty. In a private operative report, the surgeon noted that the appellant had acetabular dysplasia bilaterally. He had a total left hip arthroplasty in 2000. He recently noticed increased pain and grinding. X-rays showed a dislocation of his left hip. The surgeon noted that the revision of the left total hip arthroplasty included replacing the fractured polyethylene liner, replacing the ceramic head with a metal head of a larger size, and increasing the neck length. The surgeon indicated that the revision made the hip "quite stable." During a January 2009 VA examination, the appellant reported that he did not know that he had polio before he entered service. He stated that he fell during basic training and was sent for a medical evaluation. He related that he was discharged from service due to his hip disorder and, since that time, he had constant and progressive problems with his hips. He reported constant and severe pain in both hips with locking, giving out, and falling. He had a left hip replacement in 2001 with a revision in 2008, but he continued to have severe and constant pain. He had significant weakness in the right leg with muscle atrophy. On examination, range of motion testing of the hips was limited by weakness and increased pain. Repetitive range of motion testing improved slightly in the right hip and decreased in the left hip. He had significant muscle atrophy of the upper and lower right leg muscles with weakness, but there was no weakness or muscle atrophy on the left. There was tenderness to palpation around the anterior and posterior left hip joint and no tenderness around the right hip joint. His gait was markedly antalgic and he did not have a leg lift for his shortened right leg. A 1 inch shortening of the right leg noted. An x-ray study of the bilateral hips showed a total left hip prosthesis and moderate osteoarthritic changes present in the right hip joint. The diagnosis was degenerative joint disease of the bilateral hip joints, status-post hip replacement with revision of the left hip, secondary to polio as a child with right leg muscle wasting and leg length disparity, right leg shortening, and altered gait. The examiner provided the following opinion: ...In my opinion, it does not seem likely that the military aggravated [the appellant's] condition as he was in basic training for only 6 days. This is to[o] short a time to cause chronic degenerative problems and he did not suffer any acute injuries such as hip fracture that would lead to traumatic arthritis. Also[,] in [September 1977], he was found to already have abnormal x[-]rays/ degenerative changes of [his] bilateral hips which indicates a chronic problem. I would say that the current condition is more likely than not a progression of his preexisting bilateral hip condition. In a September 2010 private treatment note, the appellant reported a history of polio since childhood and resultant chronic pain. In a March 2012 statement, the appellant reported that when he enlisted in the Army, he passed his enlistment examination with "flying colors." He noted that, after two weeks of training as a walking soldier for front line maneuvers, sick call personnel discovered that he had a history of polio and a bilateral hip disorder. During the March 2012 hearing, the appellant testified that he reported to sick call one or two weeks into basic training, where it was determined that he had a history of polio that caused his bilateral hip disorder. He indicated that he was unaware that he had polio until that time. He stated, "[W]hen I went in the service[,] I [was] normally healthy." He related that his bilateral hip disorder was aggravated during basic training from running, carrying backpacks, and jumping. He stated that he had ongoing bilateral hip pain since basic training. During a September 2012 VA examination, the appellant reported that he injured his right hip during basic training in September 1977, and that he has had continuous right hip pain since that time. He indicated that he was medically discharged following a diagnosis of subluxation of both hips during service. He reported that his bilateral hip disorder had gradually worsened since service and he developed degenerative joint disease in both hips. On examination, the examiner noted objective evidence of pain upon range of motion testing of both hips. There was no increased pain or decreased range of motion with repetitive movements. The appellant had localized tenderness or pain to palpation in the right hip. The examiner noted that the appellant's right leg measured 101 centimeters and his left leg measured 105 centimeters in length. He had left hip replacements in 2001 and 2008 with intermediate degrees of residual weakness, pain, or limitation of motion. He also had right leg atrophy. His right thigh measured 44 centimeters whereas his left thigh measured 52 centimeters, and his right calf measured 27 centimeters whereas his left calf measured 36 centimeters. X-rays of the hips revealed degenerative or traumatic arthritis in both hips and a prosthetic left hip. The diagnosis was bilateral hip degenerative joint disease. The examiner opined that the bilateral hip disorder impacted the appellant's ability to work because he was unable to perform any work involving heavy or light physical labor due to his bilateral hip pain and unsteadiness. In a September 2012 VA addendum, the examiner opined that there was clear and unmistakable evidence that the appellant had a bilateral hip disorder at the time of entrance into service in September 1977 that was not aggravated beyond its natural progression by military service. Specifically, he noted that, although the August 1977 enlistment examination report did not include any findings pertaining to the appellant's hips, September 1977 x-ray findings included inadequate acetabula, bilaterally, with the right worse than the left; coxa magna; and subluxation of the hips, more apparent on the right than on the left. The examiner stated, "It is medically impossible that these x-ray findings could be anything but longstanding abnormalities, and they were undoubtably present prior to entrance into the military." He also noted that, on physical examination in September 1977, the appellant had a right lower extremity that was 2 1/2 inches shorter than his left lower extremity, and he had atrophy of the muscles of the right lower extremity. He stated, "It is also medically impossible that these finding[s] could be anything but longstanding, and were undoubtably present prior to entrance in the military." The examiner also noted that in a service treatment note dated on September 17, 1977, the appellant stated that, since the fifth grade, he knew that his right leg was short and atrophic. He also indicated that he was previously evaluated by a physician for his short leg and locking up of the right hip. The examiner noted that he was unable to date the onset of the bilateral hip disorder, but he indicated that the x-rays findings of inadequate acetabula, bilateral, and the diagnosis of subluxation of both hips during service "could not have been recent, and undoubtably were present prior to service." Further, the examiner opined that there was no permanent worsening of the appellant's bilateral hip disorder during service. He noted that there was no documentation of the appellant's condition from September 1977 until he filed a claim for service connection in 1993, despite the appellant's contention that he had persistent right hip pain since service. The examiner indicated that the appellant was treated for right leg lockage prior to entering service and he was treated for the same symptoms on September 17, 1977. He also reported that, during the Medical Evaluation Board proceedings, the appellant reported that he had pain in the right hip area and buttock secondary to activities of basic combat training. The examiner noted that the appellant appeared to have the same "intermittent symptoms" of "locking up of the right hip" as he had prior to service. He indicated that there was no evidence that the appellant had an acute injury to his right hip; therefore, he opined that, the appellant "likely had temporary symptoms during service similar to symptoms he had prior to entering in the service." Analysis In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to service connection for a bilateral hip disorder. In this case, the presumption of soundness applies because a physical examination at the time of his entrance into service did not find him to have a bilateral hip disorder. In fact, in the August 1977 entrance examination, the examining medical officer reported that the appellant had normal lower extremities and, in an associated report of medical history, the appellant denied a history of arthritis, rheumatism, or bursitis; and bone, joint, or other deformity. However, as an initial matter, the Board finds that the appellant had a preexisting bilateral hip disorder prior to entering service. In cases where disorders are not noted on the entrance or enlistment examination, as in this case, VA's General Counsel has clarified that VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and the the disease or injury was not aggravated by service. VAOPGCPREC 3-2003 (July 16, 2003). With respect to the first prong of the rebuttal standard, the Board finds there is clear and unmistakable evidence that the appellant's bilateral hip disorder preexisted his 34 days of service. In a September 19, 1977 orthopedic treatment note, 12 days after his enlistment, the appellant reported that, since the fifth grade, he had known that his right leg was shorter and atrophic. He also indicated that he was treated by a private physician for his short leg and "locking up" of his right hip prior to service. An x-ray of the hips showed inadequate acetabula bilaterally, worse in the right than the left, with coxa magna and subluxation of the hip, more apparent on the right than on the left. The examining orthopedist diagnosed the appellant with an atrophic right lower extremity, subluxation of both hips, and probable old polio. A September 19, 1977 report of Medical Evaluation Board proceedings reflected that the appellant had 14 days of active service, including 8 days at the reception station and 6 days of basic training. The Medical Evaluation Board noted that the appellant had subluxation of both hips and an atrophic right lower extremity. The conditions were reported to have existed prior to service, with an approximate date of origin of 1965. In the September 2012 addendum opinion, the VA examiner opined that there was clear and unmistakable evidence that the appellant had a bilateral hip disorder at the time of his entrance into service in September 1977. While he noted that the August 1977 enlistment examination report did not include findings pertaining to the bilateral hips, September 1977 x-ray findings included inadequate acetabula, bilaterally, and subluxation of the hips. He stated, "It is medically impossible that these x-ray findings could be anything but longstanding abnormalities, and they were undoubtably present prior to entrance into the military." He also reported that the x-ray findings of inadequate acetabula, bilateral, and the diagnosis of subluxation of both hips in service "could not have been recent, and undoubtably were present prior to service." Likewise, the January 2009 VA examiner noted that the September 1977 x-rays showed abnormal degenerative changes of the appellant's bilateral hips which "indicates a chronic problem." Additionally, the September 2012 examiner noted that, on physical examination in September 1977, the appellant had a right lower extremity that was 2 1/2 inches shorter than the left lower extremity, and he had atrophy of the muscles of the right lower extremity. He stated, "It is also medically impossible that these finding[s] could be anything but longstanding, and were undoubtably present prior to his entrance in the military." The Board finds that the January 2009 and September 2012 VA examiner's opinions pertaining to the appellant's preexisting bilateral hip disorder are entitled to great probative weight. The examiners reviewed the appellant's claims file, as well as his own reported medical history, and performed physical examinations of the appellant. Additionally, the Board notes that during an April 1992 SSA disability evaluation, the examining physician noted that the appellant had a history of childhood polio and residual weakness of the right lower extremity. May 1992 SSA x-rays of the pelvis and bilateral hips showed acetabular abnormalities, that the interpreting physician noted were "probable congenital anomalies" in both hips. Further, in an August 2000 private operative report, the surgeon who performed the appellant's first left hip arthroplasty noted that the appellant had acetabular dysplasia on the left "since birth" with a history of polio in the right leg. Regardless of whether the appellant knew whether he had polio prior to his enlistment, the Board finds that the record shows, by clear and unmistakable evidence, that the appellant's bilateral hip disorder preexisted service. With respect to the second prong of the rebuttal standard, the Board finds that the preexisting bilateral hip disorder was not aggravated by service. The Board notes that the Veteran sought treatment for bilateral hip complaints in service. As noted above, a September 17, 1977 sick call slip documented the appellant's complaints of a right leg "lockage," 10 days after his enlistment. In a September 19, 1977 orthopedic treatment note, the appellant complained that his right leg was "locking up" during the first week of basic combat training. He reported that he had pain in the right hip and buttocks area from the activities of basic combat training. He denied any recent significant changes in his right lower extremity. He indicated that he was treated by a physician, before enlistment, for a short right leg and "locking up" of his right hip. The September 19, 1977 report of Medical Evaluation Board proceedings reflected that the Medical Evaluation Board found that the appellant's subluxation of both hips and an atrophic right lower extremity were not caused by any incident of service and they were not aggravated during active duty. In a September 19, 1977 separation examination report, the examining medical officer noted that the appellant had an atrophic right lower extremity, subluxation of both hips, and probable old polio. Based on the foregoing, it is clear that the Veteran did have some complaints and treatment in service. However, such symptomatology alone is not enough. Instead, the evidence must show that there was an increase in his bilateral hip disorder during service that was beyond the natural progress of the disorder. A review of the evidence shows that the Veteran did not seek treatment immediately following his separation from service. In fact, the earliest post-service medical evidence is dated in April 1992, when he filed for SSA disability benefits, almost 15 years after his separation from service. The Board finds this gap in time significant, and it weighs against the existence of a link between his current bilateral hip disorder and his time in service. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (holding, in an aggravation context, that the Board may consider a prolonged period without medical complaint when deciding a claim). The September 2012 VA examiner opined that the appellant's preexisting bilateral hip disorder was not aggravated beyond its natural progression by military service. In fact, he stated that there was no permanent worsening of the appellant's bilateral hip disorder during service. He noted that the appellant was treated for right leg lockage prior to entering service, per the appellant's report during the September 19, 1977 orthopedic evaluation, and he was treated for the same symptoms in service, beginning on September 17, 1977. Additionally, during the Medical Evaluation Board proceedings, the appellant complained of pain in the right hip and buttocks area, secondary to activities of basic combat training. The examiner opined that the appellant had the same "intermittent symptoms" of locking up of the right hip during service that he had prior to service. He also indicated that there was no evidence that the appellant had an acute injury to his right hip' therefore, the appellant "likely had temporary symptoms during service similar to symptoms he had prior to entering service." As previously noted, temporary or intermittent flare-ups of symptoms of a preexisting condition, alone, do not constitute sufficient evidence for a non-combat veteran to show increased disability for the purposes of determinations of service connection based on aggravation under section 1153 unless the underlying condition worsened. Davis v. Principi, 276 F. 3d 1341, 1346-47 (Fed. Cir. 2002); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). The September 2012 VA examiner also noted that there was no documentation of the appellant's condition from September 1977 until he filed a claim for service connection in 1993. The Board notes that, in fact, the earliest post-service medical evidence is his application for SSA disability benefits, dated in April 1992. However, this was approximately one year before he filed his claim for service connection for a bilateral hip disorder. As noted above, there was an approximately 15 year gap in time from his separation from service and his earliest post-service complaints of a bilateral hip disorder. Additionally, despite his contentions that he experienced worsening bilateral hip pain since service, the Board notes that, during the April 1992 SSA disability evaluation, the appellant reported that he began having bilateral hip joint pain in the past five years. As previously discussed in the June 2012 remand, the January 2009 VA examiner's opinion was insufficient, as he applied the incorrect legal standard in his opinion. The examiner opined that the appellant's current bilateral hip disorder was "more likely than not" a progression of his preexisting bilateral hip condition. However, the standard of more likely than not, as likely as not, and less likely than not, is not the correct legal standard. Rather, 38 C.F.R. § 3.360(b) provides that "clear and unmistakable evidence" is required to rebut the presumption of aggravation where the preservice disability underwent an increase in severity during service. Additionally, the Veteran has not submitted any other medical evidence addressing whether his preexisting bilateral hip disorder permanently increased in severity beyond the natural progression of the disorder. The Board does acknowledge the appellant's contentions that his bilateral hip disorder was aggravated during service, and that he had increased bilateral hip pain since service. While lay persons may provide competent testimony as to visible symptoms and manifestations of a disorder, they are generally not competent to offer evidence which requires medical knowledge, such as opinions regarding medical causation or a diagnosis. Jones v. Brown, 7 Vet. App. 134, 137 (1994); Layno v. Brown, 6 Vet. App. 465, 469 (1994); Barr v. Nicholson, 21 Vet. App. 303 (2007); Buchanan v. Nicolson, 451 F.3d 1331 (Fed. Cir. 2006); Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). In this case, the appellant is competent to attest to his experiences and symptoms in service and thereafter. However, he is not competent to render a medical opinion indicating that increased bilateral hip pain constituted a permanent worsening of his bilateral hip disorder beyond its natural progression, as he does not have any medical training or expertise. Indeed, as previously noted, the September 2012 VA examiner specifically considered the claims file and the reported medical history, including the statements and contentions of the appellant. Nevertheless, the examiner, who is a medical professional, found that the preexisting bilateral hip disorder did not permanently worsen in severity during the appellant's military service. The Board finds that such an opinion has greater probative value than the lay statements of record. Based on the foregoing, the Board concludes that the appellant's bilateral hip disorder was not aggravated by service. Although there is evidence showing symptomatology in service, the competent and probative evidence does not indicate that such symptomatology represented a permanent worsening beyond the natural progression of the disorder, as opposed to a temporary or intermittent flare-up. Accordingly, the Board finds that the preponderance of evidence is against the appellant's claim for service connection for a bilateral hip disorder. Because the preponderance of the evidence is against the claim, the benefit of the doubt provision does not apply. Accordingly, the Board concludes that service connection for a bilateral hip disorder is not warranted. ORDER Service connection for a bilateral hip disorder is denied. ____________________________________________ CHERYL L. MASON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs