Citation Nr: 1336036 Decision Date: 11/06/13 Archive Date: 11/13/13 DOCKET NO. 09-47 910 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for a left knee disability. 2. Entitlement to service connection for a right knee disability. 3. Entitlement to service connection for a left hip disability. 4. Entitlement to service connection for a right hip disability. REPRESENTATION Appellant represented by: Virginia Department of Veterans Services ATTORNEY FOR THE BOARD C.L. Krasinski, Counsel INTRODUCTION The Veteran served on active duty from May 2007 to May 2008. He served in Iraq from August 2007 to April 2008. The Veteran also has unverified service in the Reserves. This case comes before the Board of Veterans' Appeals (Board) on appeal from an October 2008 decision of the Roanoke, Virginia, Department of Veterans Affairs (VA) Regional Office (RO), which denied the claims for service connection. In evaluating this case, the Board has not only reviewed the Veteran's physical claims file, but has also reviewed the Veteran's file on the "Virtual VA" system to ensure a complete assessment of the evidence. FINDINGS OF FACT 1. The Veteran served in the Southwest Asia theater of operations in Iraq from August 2007 to April 2008. 2. Symptoms of left and right knee pain began in service and have been recurrent since service separation. 3. The current bilateral patellofemoral pain syndrome is related to active service. 4. Symptoms of left and right hip pain began in service and have been recurrent since service separation. 5. The current left hip bursitis is related to active service. 6. The Veteran does not have a current diagnosed right hip disability. 7. A qualifying chronic disability of the right hip did not manifest during service in Southwest Asia or to a compensable degree for any six-month period since service. CONCLUSIONS OF LAW 1. The criteria for service connection for patellofemoral syndrome of the left knee are met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2013). 2. The criteria for service connection for patellofemoral syndrome of the right knee are met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2013). 3. The criteria for service connection for left hip bursitis are met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2013). 4. The criteria for service connection for a right hip disability manifested by pain and as due to a qualifying chronic disability, have not been met. 38 U.S.C.A. §§ 1110, 1117, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.317 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). When VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and the representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). VA 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. 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 a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. The Court of Appeals for Veterans Claims (Court) held that the VCAA notice must include notice that a disability rating and an effective date of the award of benefits will be assigned if service connection was awarded. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Regarding the claims for service connection for bilateral knee patellofemoral syndrome and left hip bursitis, to the extent that the action taken hereinbelow is favorable to the Veteran, further discussion of VCAA is not required at this time. Regarding the claim for service connection for a right hip disability, the Board finds that the VCAA notice requirements have been satisfied by a letter dated in June 2008. This letter was issued prior to the initial adjudication of the claim. VA has a duty to assist a veteran in the development of the claim. This duty includes assisting the veteran in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board notes that the Veteran's service treatment records are associated with the claims folder. VA treatment records dated from 2008 to 2009 are associated with the claims folder. The Veteran did not identify any treatment for the right hip disability. VA provided examinations in 2008 and 2009 to obtain medical evidence as to the nature and likely etiology of the claimed disorder. The examinations are adequate because the examinations were performed by medical professionals based on review of claims file, solicitation of history and symptomatology from the Veteran, and an examination of the Veteran. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4). For these reasons, the Board finds that the duties to notify and assist the Veteran have been met, so that no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002). The Board finds that no reasonable possibility exists that any other assistance would aid in substantiating the claims and VA met its duty to assist the Veteran. Laws and Regulations Service connection will be granted for disability resulting from a disease or injury incurred in or aggravated by military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection requires competent evidence showing, (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, 1167 (Fed. Cir. 2004), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may also be granted on a presumptive basis for a Persian Gulf Veteran who exhibits objective indications of qualifying chronic disability, including resulting from undiagnosed illness, that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 21, 2016, and which by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317(a)(1). In claims based on qualifying chronic disability, unlike those for "direct service connection," there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Notably, laypersons are competent to report objective signs of illness. A "qualifying chronic disability" for VA purposes is a chronic disability resulting from (A) an undiagnosed illness, (B) a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome (CFS), fibromyalgia, or irritable bowel syndrome) that is defined by a cluster of signs or symptoms, or (C) any diagnosed illness that the Secretary determines in regulation prescribed under 38 U.S.C.A. § 1117(d) warrants a presumption of service connection. 38 U.S.C.A. § 1117(a)(2); 38 C.F.R. § 3.317(a)(2)(i)(B). "Objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to a physician, and other, non-medical indicators that are capable of independent verification. To fulfill the requirement of chronicity, the illness must have persisted for a period of six months. 38 C.F.R. § 3.317(a)(2), (3). Signs or symptoms that may be manifestations of undiagnosed illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; and (12) abnormal weight loss. 38 C.F.R. § 3.317(b). Effective July 13, 2010, VA has amended its adjudication regulations governing presumptions for certain Persian Gulf War Veterans. Such revisions amend 38 C.F.R. § 3.317(a)(2)(i)(B) to clarify that CFS, fibromyalgia, and irritable bowel syndrome are examples of medically unexplained chronic multisymptom illnesses and are not an exclusive list of such illnesses. Additionally, the amendment removes 38 C.F.R. § 3.317(a)(2)(i)(B)(4) which reserves to the Secretary the authority to determine whether additional illnesses are "medically unexplained chronic multisymptom illnesses" as defined in subsection 38 C.F.R. § 3.317(a)(2)(ii) so that VA adjudicators will have the authority to determine on a case-by-case basis whether additional diseases meet the criteria of 38 C.F.R. § 3.317(a)(2)(ii). These amendments are applicable to claims pending before VA on October 17, 2010, as well as claims filed with or remanded to VA after that date. See 75 Fed. Reg. 61,997 (October 7, 2010). Compensation under 38 U.S.C.A. § 1117 shall not be paid if there is affirmative evidence that: (1) an undiagnosed illness was not incurred during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War; (2) an undiagnosed illness was caused by a supervening condition or event that occurred between the Veteran's most recent departure from active duty in the Southwest Asia theater of operations during the Persian Gulf War and the onset of the illness; or (3) the illness is the result of the Veteran's own willful misconduct or the abuse of alcohol or drugs. 38 C.F.R. § 3.317(c). The term "Persian Gulf Veteran" means a veteran who served on active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War. 38 C.F.R. § 3.317(e)(1). The "Southwest Asia theater of operations" refers to Iraq, Kuwait, Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317(e)(2). With disability compensation claims, VA adjudicators are directed to assess both medical and lay evidence. In addressing lay evidence and determining its probative value, if any, attention is directed to both competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). See Layno v. Brown, 6 Vet. App. 465, 469 (1994). In terms of competency, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. See generally Caluza v. Brown, 7 Vet. App. 498 (1995). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 7105; 38 C.F.R. §§ 3.102, 4.3, 4.7. Analysis The Veteran contends that he incurred disabilities of the hips and knees in active service. He argues in the alternative, the service-connected lumbar spine degenerative disc disease caused or aggravated the claimed disabilities. There is competent and credible evidence that the Veteran has had symptoms of pain in the hips and knees in active service and since active service. The Veteran separated from active service in May 2008. He filed his claim for compensation benefits in June 2008. VA primary care treatment records dated in June 2008 indicate that the Veteran was a new patient to the clinic. It was noted that his biggest complaint was pain in various joints including both hips and knees which was worse with activity. Musculoskeletal examination revealed normal strength in the lower extremities. Joint examination revealed no abnormalities. There was full range of motion of the hips and knees. The assessment was polyarthralgias, etiology unknown, will exclude connective tissue disease. The July 2008 VA examination report indicates that the Veteran reported having bilateral hip and sacroiliac pain and bilateral knee pain in service during physical training and especially when sitting crossed leg. The Veteran also reported having stiffness in the knees and some locking on the left. He stated that the knee symptoms have not improved since his return from deployment. The Veteran stated that he used to be able to bike ride before his deployment but he no longer does because of the hip pain and his bilateral knee pain. The hip pain symptoms were intermittent with remissions; the bilateral knee symptoms were stable. He currently treated the hip and knee pain with ibuprofen. The Veteran reported that these symptoms began in June 2007 and occurred during active service. Physical examination revealed that the Veteran had a normal gait. All muscle groups were normal with 5/5 muscle strength. There was no wasting or atrophy. Range of motion of both hips was zero degrees to 125 degrees on flexion and zero degrees to 45 degrees on abduction which is normal. See 38 C.F.R. § 4.71a, Plate II. There was no evidence of pain with motion in the hips. Range of motion of both knees was zero degrees to 140 degrees on flexion which is normal. See 38 C.F.R. § 4.71a, Plate II. There was no evidence of pain with motion in the knees. There was no evidence of tenderness or other abnormality in the hips. There was no evidence of pain, tenderness, effusion, laxity, or tendon abnormalities in the knees. There was normal patellar tracking and menisci. June 2008 X-ray examinations of both knees and hips were normal and revealed no significant abnormalities. The diagnoses were arthralgia of both hips and arthralgia of both knees. VA treatment records dated in June 2009 indicate that the Veteran reported that his joints ache like he has aged 20 years. VA primary care treatment records dated in September 2009 indicate that the Veteran had knee pain. The Veteran was referred for orthopedic examination. A September 2009 VA Persian Gulf examination noted that the Veteran had polyarthralgias. Physical examination of the hips revealed good active range of motion. Examination of the knees revealed subpatellar tenderness bilateral and fluid on the left. There was no instability or grinding. The diagnosis in pertinent part was bilateral patellofemoral syndrome. An October 2009 VA chiropractic treatment record indicates that there was limitation of flexion of the hips. Right hip flexion was to 85 degrees and left hip flexion was to 88 degrees. Hip flexion and toe walking was limited by pain in the area of the complaints which was in the area of the left thigh and buttock. A July 2012 VA QTC examination report shows a diagnosis of left hip bursitis. The report notes that the left hip condition has existed since 2010 when the Veteran served in Iraq; the disorder began after strenuous activity. The Veteran reported having deep pain in the gluteus area possibly over the greater trochanter with standing and walking. The Veteran reported having stiffness, swelling, lack of endurance, fatigability, tenderness and pain. He reported having flare-ups one time a day and the severity of the flare-up was a 7 out of 10 (1 to 10, 10 was worst). The flare-ups were precipitated by physical activity and were alleviated by rest and pain medications. Physical examination revealed normal gait. Examination of the right hip showed no signs of edema, instability, abnormal movement, effusion, weakness, tenderness, redness, heat, deformity, misalignment, drainage, subluxation, or guarding of movement. Examination of the left hip revealed tenderness and pain on deep palpation over the greater trochanter area. The left hip showed no signs of edema, instability, abnormal movement, effusion, weakness, redness, heat, deformity, guarding of movement, mal-alignment, or drainage. Range of motion of the right hip was within normal limits with no pain or any additional limitation of motion. Repetitive range of motion was possible. Range of motion of the left hip was within normal limits but there was evidence of pain at 45 degrees of abduction, 60 degrees of external rotation, and 40 degrees of internal rotation. There was no additional limitation of motion due to pain. Repetitive range of motion was possible. The left and right hip joints were not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. Left hip x-ray examination was within normal limits. The diagnosis in pertinent part was left hip bursitis with subjective factors of a history of hip pain with persistent activity and objective factors of pain on range of motion of the hip joint. The Board finds that the evidence is in equipoise on the question of whether the Veteran's current bilateral knee disabilities, diagnosed as patellofemoral syndrome, and the left hip disability, diagnosed as left hip bursitis, are related to active service. There is evidence which tends to show that the Veteran had symptoms of pain in the hips and knees in service and these symptoms have been recurrent since service separation. The evidence discussed above also shows that the Veteran reported having these symptoms within a month of service separation and he continued to report having pain in the left hip and bilateral knees. The Veteran is competent to describe observable symptoms such as hip and knee pain. A lay person is competent to testify as to observable symptoms. See Falzone v. Brown, 8 Vet. App. 398, 403 (1995). The Veteran's lay statements are found to be credible as they have been consistent since his separation from service. The Veteran's reports of hip and knee pain since service have been made to health care providers in connection with medical treatment and were made soon after service separation. The Board finds that the Veteran's statements made in the course of medical treatment to have great probative value because statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997). There is medical evidence which establishes that the symptoms of bilateral knee pain were due to the diagnosis of patellofemoral syndrome of the bilateral knees. The September 2009 VA evaluation report indicates that the examiner considered the Veteran's reported medical history of knee pain and bilateral patellofemoral syndrome was diagnosed. The July 2012 VA examination report also noted that Veteran's report of left hip pain and the diagnosis was left hip bursitis. The Board finds that this is probative medical evidence which relates the current diagnoses to the pain symptoms. This lay and medical evidence supports a grant of service connection for left hip bursitis and bilateral knee patellofemoral syndrome. There is evidence which weighs against the claims for service connection. The service treatment records do not document any complaints or findings referable to hip or knee pain or disabilities. The July 2012 VA examination report notes that the Veteran reported that the left hip pain began in 2010. However, the Board finds that the more probative lay and medical evidence establishes that the left hip and knee symptoms of pain began in service and have been recurrent since that time. The report of left hip pain beginning in 2010 is inconsistent with the Veteran's lay statements concerning the onset of the left hip pain and the medical evidence and treatment records which document complaints of pain soon after service separation in May 2008. After affording the Veteran the benefit of the doubt, the Board finds that the Veteran's bilateral knee patellofemoral syndrome and left hip bursitis first began in service, have been recurrent since service, and still exist. The Board further finds that the Veteran's statements regarding the symptoms of pain in service and since service to be competent and credible. The Board finds that the Veteran's statements to be sufficient proof of in-service symptoms and recurrent post service symptoms. The Veteran's lay statements are found to be credible as they have been consistent and are contemporaneous to his period of service. Based on a careful review of the entire record, the Board finds the evidence is in equipoise as to whether the current bilateral knee patellofemoral syndrome and left hip bursitis as likely as not began during his period of active service. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). In resolving all reasonable doubt in the Veteran's favor, service connection for bilateral knee patellofemoral syndrome and left hip bursitis is warranted. Regarding the claim for service connection for a right hip disability, the weight of the competent and credible evidence shows that the Veteran does not have a current right hip disability. The service treatment records, VA treatment records, and VA examination reports do not show diagnosis of a right hip disability. The VA examination reports and VA treatment records show that examination of the right hip was within normal limits with the exception of some limitation of flexion upon examination in October 2009. X-ray examination of the right hip was normal. The July 2012 VA QTC examination report indicates that physical examination of the right hip showed no signs of edema, instability, abnormal movement, effusion, weakness, tenderness, redness, heat, deformity, misalignment, drainage, subluxation, or guarding of movement. Range of motion of the right hip was within normal limits with no pain or any additional limitation of motion. Repetitive range of motion was possible. The right hip joint was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. A right hip diagnosis was not made. As discussed above, the Veteran's lay statements that he has had right hip pain in service and since service are competent and credible. However, there is no competent evidence which relates this symptom to a diagnosed disorder. The Court has held that a symptom, alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability. Without a pathology to which the symptoms can be attributed, there is no basis to find a disability for which service connection may be granted. See Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999) ("pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted."); dismissed in part and vacated in part on other grounds, Sanchez-Benitez v. Principi, 239 F.3d 1356 (Fed. Cir. 2001). The weight of the medical evidence is against the Veteran's lay assertions that he has a right hip disability. While the Veteran is competent to state that he has observable symptoms, he is not competent to render a medical diagnosis. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis); see also Jones v. West, 12 Vet. App. 383, 385 (1999) (where the determinative issue is one of medical causation or a diagnosis, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue). There is no evidence showing that the Veteran has medical expertise and he is not competent to provide any medical diagnoses or medical opinions. The Court has held that Congress specifically limited entitlement to service connected benefits to cases where there is a current disability. "In the absence of proof of a present disability, there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Without competent evidence of a diagnosed disability, service connection for the disorder cannot be awarded. See Brammer; supra; Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004) (holding that service connection requires a showing of current disability); see also Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998) (holding that a grant of service connection requires that there be a showing of disability at the time of the claim, as opposed to sometime in the distant past). Accordingly, on this record, the evidence is found to preponderate against the claim that the Veteran has a right hip disability that was incurred in service. The weight of the evidence establishes that the Veteran does not have a current diagnosis of a right hip disability. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Accordingly, the claim of service connection for a right hip disability is denied. The Board also finds the weight of the competent and credible evidence is against a finding that the Veteran has a qualifying chronic disability manifested to a compensable degree for any six-month period since service. Service connection may be granted on a presumptive basis for a Persian Gulf Veteran who exhibits objective indications of qualifying chronic disability, including resulting from undiagnosed illness, that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 21, 2016, and which by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317(a)(1). "Objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to a physician, and other, non-medical indicators that are capable of independent verification. To fulfill the requirement of chronicity, the illness must have persisted for a period of six months. 38 C.F.R. § 3.317(a)(2), (3). In this case, the weight of the competent and credible evidence establishes that the Veteran does not have objective indications of a chronic disability manifested in service or to a compensable degree for any six-month period since service. A hip disability is rated under Diagnostic Codes 5250 to 5255. Under Diagnostic Code 5251, a 10 percent rating is assigned for limitation of extension to 5 degrees. Under Diagnostic Code 5252, limitation of flexion of the thigh, a 10 percent rating is assigned for flexion limited to 45 degrees. Under Diagnostic Code 5253, impairment of the thigh, the criteria for a 10 percent rating is the inability to cross the legs or external rotation limited to 15 degrees. Normal extension of the hip is to zero degrees, and normal flexion is to 125 degrees. Normal abduction is to 45 degrees. See 38 C.F.R. § 4.71a. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Functional loss may be due to due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40 (2013). Weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity, or atrophy of disuse are relevant factors in regard to joint disability. 38 C.F.R. § 4.45 (2013). In this case, the weight of the competent and credible evidence establishes that the Veteran does not have objective indications of a chronic disability of the right hip manifested in service or to a compensable degree for any six-month period since service. There is competent and credible evidence of right hip pain in service. However, there are no objective findings of painful motion, functional loss of the right hip, limitation of motion of the right hip or any other objective findings during service. Examination of the right hip soon after service separation shows that the right hip was normal with no findings of limited motion, pain on motion, or other objective findings of a chronic disability. See the June and July 2008 VA evaluations and treatment records. For the time period after service, the weight of the evidence shows that the Veteran does not have any objective findings pertinent to the right hip except upon examination in October 2009. On examination in October 2009, flexion of the right hip was limited to 85 degrees. This does not meet the criteria for a 10 percent rating under Diagnostic Code 5252. For a compensable rating under Diagnostic Code 5252, flexion must be limited to 45 degrees. The weight of the evidence shows that the Veteran had flexion of the right hip well beyond 45 degrees. Further, there are no objective findings of swelling, muscle spasm, or satisfactory evidence of painful motion of the right hip. There was no objective evidence of pain with motion of the right hip. Examination of the right hip was normal in July 2012. The Board finds the weight of the evidence demonstrates that the Veteran has not exhibited objective indications of a qualifying chronic disability manifested in service or to a compensable degree for any six-month period since service. While the evidence establishes that the Veteran has had complaints of right hip pain in service and since service, there is no competent evidence which shows that the symptoms of pain causes any functional impairment which warrants a compensable rating under the pertinent rating criteria. At no time does the symptom of pain impair the right hip so that there is a loss of flexion beyond 45 degrees, extension limited to 5 degrees, limitation of rotation of the leg, or a loss of adduction. A qualifying chronic disability of the right hip did not manifest during service in Southwest Asia or to a compensable degree for any six-month period since service. Thus, presumptive service connection for a disability manifested by right hip pain as due to a qualifying chronic disability is not warranted. The weight of the evidence is against service connection for a presumptive qualifying chronic disability manifested to a compensable degree for any six-month period since service. See 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317. For the reasons and bases discussed above and after a review of all the evidence, both lay and medical, the Board finds that a preponderance of the evidence is against the claim for service connection for a right hip disability manifested by pain as directly incurred in service and as presumptively due to a qualifying chronic disability; therefore, this claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. ORDER Service connection for left knee patellofemoral syndrome is granted. Service connection for right knee patellofemoral syndrome is granted. Service connection for left hip bursitis is granted. Service connection for a right hip disability to include a chronic qualifying disability is denied. ____________________________________________ M. TENNER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs