Citation Nr: 1337417 Decision Date: 11/15/13 Archive Date: 11/26/13 DOCKET NO. 11-17 511 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana THE ISSUE Entitlement to service connection for right hip and back disabilities, claimed as secondary to service connected arthritis of the right knee. REPRESENTATION Veteran represented by: Karl A. Kazmeirczak, Esq. WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Matthew Blackwelder, Counsel INTRODUCTION The Veteran served on active duty from August 1952 to May 1954. This appeal comes to the Board of Veterans' Appeals (Board) from an April 2009 rating decision. The Veteran had previously sought service connection for the disabilities on appeal, but his claims were denied by a 2006 Board decision. In 2008, the Veteran sought to reopen his claim, and the Board did reopen his claim in September 2012, before remanding it for additional development. The directed development has been completed, and because the Board's order was fully complied with, there is no prejudice for the Board to proceed. See Stegall v. West, 11 Vet. App. 268 (1998). As a result of the Veteran's claim being reopened, the Board will consider the entirety of the evidence of record, including medical and lay evidence generated in conjunction with his previously denied claim. The Board must note that in reviewing this case the Board has not only reviewed the Veteran's physical claims file, but also his file on the "Virtual VA" system to insure a total review of the evidence. The Veteran testified before the undersigned Veterans Law Judge at a July 2012 videoconference hearing, and a transcript of this hearing is of record. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). 38 U.S.C.A. § 7107(a)(2). FINDINGS OF FACT 1. Neither a right hip nor back injury or disability was shown in service. 2. Neither a right hip, nor back, disorder, currently diagnosed as arthritis, was shown to a compensable degree within one year of service; and the Veteran's back and right hip symptoms began many years after service and were not continuous since service. 3. A current right hip and or back disorder is not causally or etiologically related to service; and neither was caused or aggravated by the Veteran's service connected right knee disability. CONCLUSION OF LAW Criteria for service connection for arthritis of the right hip and/or back have not been met. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303, 3.307, 3.309, 3.310 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Service Connection Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). In this case, the Veteran is seeking service connection for right hip and lower back disabilities, currently diagnosed as degenerative joint disease or arthritis, which he believes are the result of his service connected right knee disability. Service connection can be established on a presumptive basis, on a direct basis, or on a secondary basis. Each of these bases will be considered and discussed below. Presumptive Service Connection Service connection may be established under 38 C.F.R. § 3.303(b), if a chronic disease or injury is shown in service, and subsequent manifestations of the same chronic disease or injury at any later date, however remote, are shown, unless clearly attributable to intercurrent causes. For a showing of a chronic disorder in service, the mere use of the word chronic will not suffice; rather, there is a required combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. In this case, the Veteran has been diagnosed with degenerative joint disease of the spine and right hip. Degenerative joint disease is listed as a "chronic disease" under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) applies. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (holding that the "chronic" in service and "continuous" post-service symptom presumptive provisions of 38 C.F.R. § 3.303(b) only apply to "chronic" diseases at 3.309(a)). Service connection may also be established with certain chronic diseases, including arthritis (degenerative joint disease), based upon a legal presumption by showing that the disorder manifested itself to a degree of 10 percent disabling or more within one year from the date of separation from service. Such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. The evidence of record shows that the Veteran was involved in a motor vehicle accident while in service, which was ultimately found to have caused the arthritis in his right knee. As such, service connection is in effect for the Veteran's right knee. However, service medical records are absent any findings of, treatment for, or a diagnosis of degenerative joint disease of either the lumbar spine or the right hip. The reports from the Veteran's enlistment and separation physicals both note that he had a normal spine/musculoskeletal system and normal lower extremities, providing evidence against this claim. Additionally, following service, there is no medical evidence of any hip or back disability for a number of years. At a VA examination in 1960, the Veteran reported being injured in a jeep accident in service in 1954 where he injured his right knee, and cut his chin and right hand. The Veteran complained that his right knee, foot and hip all hurt, and that his knee would swell up. However, on physical examination, the examiner found that the Veteran walked quite normally, and opined that his complaints of pain in the right lower extremity were without foundation. He added that a careful examination of the Veteran's musculoskeletal system failed to reveal any abnormality significant or otherwise, with the exception of several scars. Private treatment records from 1969 show that the Veteran had full range of motion in his right hip without any sensory loss, and x-rays of the hip were grossly negative. Furthermore, impressions of degenerative joint disease of the back and hip were first noted beginning sometime in the 1990s (statement submitted by Dr. E. in February 1995), approximately four decades after separation. As described, there is no showing that degenerative joint disease of the back or right hip began during service or within a year of service. Moreover, there is no showing that back and right hip problems have existed continuously since service, as the Veteran did not complain of either condition in service, or for many years thereafter. The Veteran does not dispute these conclusions, as he testified at a hearing before the Board in July 2012 that he did not have a hip or back disability during service, and that his primary contention was that his service connected right knee disability had caused his right hip and back problems. Accordingly, service connection is not warranted on a presumptive basis. Direct Service Connection Even when a disease is first diagnosed after discharge, service connection may still be awarded if the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). This has been interpreted as a three-element test based on nexus: (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 in or aggravated by service. See Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). At hearing before the Board in July 2012, the Veteran testified that he did not have a hip or back disability during service, and that his primary contention was that his service connected right knee disability had caused his right hip and back problems. Nevertheless, because several of the medical opinions of record have appeared to allow for the possibility of direct service connection, the Board will consider this theory of entitlement. As noted, the Veteran has current back and right hip disabilities, namely degenerative joint disease or arthritis. It has also been acknowledged that he was involved in a motor vehicle accident during service which would constitute a potential in-service injury. However, the occurrence of an in-service accident and the presence of a current disability are not sufficient to establish service connection; rather, the accident must be shown to have caused the current disability. As noted, service treatment records do not show any treatment for back or right hip problems following the accident. The Veteran's separation physical also found his spine and lower extremities to be normal. Following service, no treatment is of record for more than six years until a VA examination was conducted in October 1960. As noted, the Veteran did report right hip pain at this time, but the examiner on physical examination found no right lower extremity disability at that time. Moreover, in 1969, x-rays of the right hip were grossly negative, and it was thought that the Veteran might have sciatic neuritis. Specific back and right hip disabilities were not diagnosed for more than four decades after service, as a February 1995 statement by Dr. E. marks the first impression of arthritis of either the back or hip. Specifically, in February 1995, the Veteran was noted to have been seen with complaints of increased difficulty walking due to pain in his lower back, right hip and right knee. It was felt that he had osteoarthritis in his back, hip and knee. Several medical opinions have been advanced regarding the etiology of the Veteran's back and hip disabilities. In a July 2001 VA examination report, a VA examiner noted the Veteran's history or right knee pain and swelling. He indicated that the Veteran had recently developed pain in his right hip and lower back, which the examiner found were probably age related. He observed that the Veteran did not limp when ambulating, but he did experience difficulty walking on his toes because of a pulling sensation in his right knee. The Veteran demonstrated full range of motion in both knees. In July 2001, Dr. E. wrote that the Veteran had been recently evaluated for increasing back and right hip pain, as the result of degenerative joint disease. Dr. E. stated that it was quite likely that the Veteran's back pain and degenerative joint disease may be related to his original injury while in service. In September 2001, the Veteran wrote a statement in which he asserted that the arthritis in his hip and back were related to his original injury in service. It is noted that such a statement potentially conflicts with his testimony to the Board and his assertion at his February 2002 VA examination that his right hip pain was the result of his knee injury. At a February 2002 VA examination, the examiner opined, after reviewing the claims file and examining the Veteran, that the degenerative joint disease in the Veteran's lumbosacral spine was not related to his in-service injury and was simply due to old age. In an August 2002, notice of disagreement, the Veteran objected to the finding that the arthritis in his back and hips was age related, suggesting once again that they resulted from his in-service injury, and/or to the knee disability which resulted. Pursuant to a January 2004 remand, VA afforded the Veteran an examination April 2004 to once again investigate the etiology of his current lumbar spine and right hip disabilities and to reconcile the various medical opinions. The examiner reviewed the claims folder and examined the Veteran. The Veteran reported that he had begun experiencing discomfort in his lumbosacral spine and into the right hip in approximately 2001 when he was 70 years of age. Walking reportedly improved the hip and back, while prolonged sitting caused the conditions to worsen. The examiner observed that the Veteran's onset of discomfort in the hips and back was relatively recent. He noted that the degenerative joint disease in the Veteran's lumbosacral spine and in his right hip was compatible with his age. The VA examiner reviewed the private medical opinions that were noted above, but specifically disagreed with their conclusions. The examiner explained that the Veteran's right knee disability was not responsible for his hip disability because there was no history of a significant lurging gait as would be expected with unusual strains on the hips and the low back. He explained that the current disabilities were not related to an injury in 1954, because if the in-service injury was severe enough to cause early deterioration the hip and back, such deterioration would have occurred long before it actually did in the Veteran's case. Instead, because the changes in the lumbar spine and hips were of recent onset and were of mild degree, the examiner found that the changes were unlikely to be secondary to the Veteran's service-connected right knee injury. The examiner also noted that the changes in the back and hip were recent and were consistent with what the examiner would expect to see in a majority of the people in the Veteran's age group. In October 2009, Dr. O. wrote that he had been treating the Veteran since 2004 for right knee, right hip, and sacro-iliac joint problems. Dr. O. opined that the Veteran's symptoms were traceable to his "combat related injuries in the 1950s." Another VA examination was provided in March 2013. The examiner reviewed the claims file and examined the Veteran. He then opined that it was less likely than not that the Veteran's lower back and/or right hip disabilities were incurred in or caused by his in-service injury. The examiner explained that orthopedic literature disputes the suggestion that an injured lower limb with normal extension produces an overload and therefore injury to the opposite normal limb or the lower back. In fact, there was no overload found, even in such situations of compromise as when the injured limb is post polio or amputation with rosthesis, unless there is a contracture of the bad knee or injuries to the good knee from repetitive falls from the bad knee giving way, which was not the disability picture presented in the Veteran's case. Additionally, the examiner noted that the Veteran had a normal gait since his right knee problems were mild. The examiner diagnosed the Veteran with mild degenerative disc disease/degenerative joint disease in his back that was better than age typical. The Veteran was noted to have first been seen for his back in approximately 1996, but no falls had been documented as a result of his right knee. The examiner diagnosed the Veteran with mild degenerative joint disease in his right hip that was better than age typical. At this juncture, the Board notes that as finder of fact, it must determine, both the weight and credibility of all the evidence of record. To this end, equal weight is not accorded to each piece of evidence contained in a record; and every item is not considered to have the same probative value. Rather, the Board must account for the evidence which it finds to be persuasive or unpersuasive, analyze the credibility and probative value of all material evidence submitted by and on behalf of a claimant, and provide the reasons for its rejection of any such evidence. See Struck v. Brown, 9 Vet. App. 145, 152 (1996); Caluza v. Brown, 7 Vet. App. 498, 506 (1995). The Board acknowledges that several of the private opinions are from the Veteran's treating physician. However, the Court has expressly rejected a rule that the opinions of private treating physicians are entitled to presumptively greater weight in evaluating veterans' claims. Guerrieri v. Brown, 4 Vet. App. 467, 473 (1993). When evaluating the evidence of record, the Board must assess the credibility and probative value of the evidence, and, provided that it offers an adequate statement of reasons or bases, the Board may favor one medical opinion over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995); Wood v. Derwinski, 1 Vet. App. 190 (1991). As discussed above, several medical opinions are of record discussing whether the Veteran's current right hip and back disabilities were the result of his military service. There are two opinions which attempt to link the Veteran's back and right hip to service. Dr. E.'s opinion in July 2001 suggested that it was quite likely that the Veteran's back pain and degenerative joint disease may be related to his original injury while in service. However, this opinion was phrased in a highly speculative manner, and "may be" in the context of a medical opinion is the same as "may not be" and therefore cannot provide the requisite nexus. See Obert v. Brown, 5 Vet. App. 30, 33 (1993). Moreover, Dr. E. subsequently issued multiple opinions relating the Veteran's back and hip disabilities to an alleged altered gait that was caused by his service connected right knee disability. As such, the fact that the doctor later changed his theory of causation undermines the probative value of the July 2001 opinion. Finally, no rationale was provided for Dr. E.'s conclusion. The other positive nexus opinion was provided by Dr. O. who opined that the Veteran's symptoms were traceable to his "combat related injuries in the 1950s." However, it is noted that while the Veteran served during the time of the Korean War, he never served overseas and therefore he was never exposed to combat. As such, this clear lack of familiarity with the Veteran's medical and service history, significantly undermines the probative value of the opinion. See Miller v. West, 11 Vet. App. 345, 348 (1998) (a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record). Conversely, several highly probative opinions have been provided by VA examiners. Specifically, in 2004 and 2013, VA examiners explained why the Veteran's degenerative joint disease in his back and right hip were more likely to be age related than caused by his military service. The 2013 opinion was supported by research in the medical literature. It is also noted that the VA examiners had access to the Veteran's claims file, which is relevant here in that it gave them perspective as to the extent of the in-service motor vehicle accident, and post-service treatment, or lack thereof. Conversely, one of the private opinions was based on combat exposure that the Veteran simply did not have, show a clear lack of familiarity with the Veteran's history. The private medical opinions were provided by medical professionals and therefore their opinions are considered competent evidence. However, given the flaws in the opinions, such as the lack of any rationale and factual error underlying the opinion, the probative value of the opinions is greatly reduced. In this case, the VA examiners' opinions were simply supported by better rationales and better grounded in the Veteran's medical history than were the statements by the private medical professionals. As such, the VA opinions are afforded greater weight; and for that reason, service connection on a direct basis is not warranted as there is no suggestion that the Veteran's back or right hip disabilities were the direct result of an injury in service. Secondary Service Connection Service connection may also be awarded for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Any additional impairment of earning capacity resulting from an already service-connected condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected condition, should also be compensated. Allen v. Brown, 7 Vet. App. 439 (1995). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. Id. As noted above, the Veteran's primary contention is that his service connected right knee disability caused or aggravated his back and right hip. At a Board hearing in November 2000 (that was the subject of a previous final Board decision), the Veteran's representative stated that the Veteran's right knee pain and degenerative arthritis were beginning to affect his gait, and the Veteran added that his right knee was affecting his right hip and back. As a lay person, is competent to report what comes to him through his senses, and he therefore may report symptoms such as knee, hip, or back pain. See Layno v. Brown, 6 Vet. App. 465 (1994). However, he lacks the medical training and expertise to provide a complex medical opinion as to the etiology of an orthopedic disability. See Layno v. Brown, 6 Vet. App. 465 (1994), Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). As such, his opinion is insufficient to provide the requisite nexus in this case. A number of medical opinions are of record discussing the relationship between the Veteran's right knee disability and his back and right hip disabilities. In May 2000, Dr. E. wrote that he had first treated the Veteran in 1991 for right knee pain. He noted that the Veteran remained symptomatic with pain in his right knee, accompanied by difficulty walking. Dr. E. noted that the Veteran had also developed pain in his lower back and in his right hip in recent years, which Dr. E. suggested were most likely directly related to arthritis in his right knee. However, no rationale was provided for this opinion. In a July 2001 VA examination report, a VA examiner noted the Veteran's history or right knee pain and swelling. He indicated that the Veteran had recently developed pain in his right hip and lower back, which the examiner opined were probably age related. He observed that the Veteran did not limp when ambulating, but he did experience difficulty walking on his toes because of a pulling sensation in his right knee. The Veteran demonstrated full range of motion in both knees. In February 2002, the Veteran underwent a VA examination at which his in-service motor vehicle accident was discussed. The examiner acknowledged the Veteran's contention that his right hip pain, which began approximately three years earlier, was the result of his knee injury. X-rays showed degenerative joint disease of the lumbosacral spine and degenerative joint disease of both hips which was early and mild. The examiner stated that the degenerative joint disease of the lumbosacral spine and of the knees was not related to his in-service injury and was simply due to old age. In January 2003, Dr. E. wrote that the Veteran continued to have osteoarthritic pain in his lower back and right hip, he then opined that it was more likely than not that the arthritis in the Veteran's lower back and hip was secondary to the arthritis in his right knee. In February 2003, Dr. O. wrote that it was more likely than not that the Veteran's back and right hip pain were causally related to his right knee pathology. However, in October 2009, Dr. O. opined that the Veteran's symptoms were traceable to his "combat related injuries in the 1950s." This statement as noted above is patently inaccurate as the Veteran never even served abroad. Given this clear lack of familiarity with the Veteran's medical and service history, greatly diminishes the probative value of Dr. O.'s opinions. Additionally, no rationale was provided in either of his letters. Pursuant to a January 2004 remand, VA afforded the Veteran an examination April 2004 to investigate the etiology of his current lumbar spine and right hip disabilities and to reconcile the various medical opinions. The examiner reviewed the claims folder and examined the Veteran. The Veteran reported that he had begun experiencing discomfort in his lumbosacral spine and into the right hip in 2001 when he was 70 years of age. Walking reportedly improved the hip and back, while prolonged sitting caused the conditions to worsen. The examiner observed that the Veteran's onset of discomfort in the hips and back was relatively recent. He noted that the degenerative joint disease in the Veteran's lumbosacral spine and in his right hip was compatible with his age. The VA examiner reviewed the private medical opinions that were noted above, but specifically disagreed with their conclusions. The examiner explained that the Veteran's right knee disability was not responsible for his hip disability because there was no history of significant lurging gait as would be expected with unusual strains on the hips and the low back. He explained that the current disabilities were not related to an injury in 1954, because if the in-service injury was severe enough to cause early deterioration the hip and back, such deterioration would have occurred long before it actually did in the Veteran's case. Because the changes in the lumbar spine and hips were of recent onset and were of mild degree, the examiner found that those changes were unlikely to be secondary to the Veteran's service-connected right knee injury. The examiner also noted that the changes in the back and hip were recent and were consistent with what the examiner would expect to see in a majority of the people in the Veteran's age group. It was added that it was unlikely that service-connected disability aggravated the hip and/or back disorders. In July 2008, Dr. D. wrote that the Veteran sustained a right knee injury in 1952 or 1953 while on active duty and had experienced lower back and bilateral hip pain for the previous five years. Dr. D. stated that it was more likely than not that the Veteran's back and hip problems were the result of an abnormal gait that resulted from his in-service knee injury. In August 2008, Dr. E. wrote that having reviewed the attached medical opinion and VA decision, he believed that it was more likely than not that the traumatic arthritis in the Veteran's right knee caused his current hip and back conditions. He indicated that it was his belief that the Veteran had dealt with an altered walking gait, off and on since 1954 and that the limp was more likely the cause of the mild to moderate back and hip disabilities. Dr. E. added that there was no link other than his knee injury. In July 2012, the Veteran testified at a hearing before the Board. He indicated that when he underwent his VA examinations in 2002 and 2004, the examiners found that he had a normal gait. However, the Veteran maintained that even then he had a limp. He then described how he had been receiving treatment from several private medical professionals who were all familiar with his claim. The Veteran's representative asked him when he started limping, to which the Veteran replied that it was around 2002 or 2003. The representative then asked the Veteran when he developed his hip and back problems, to which he asserted that he had experienced them for 6-7 years, since 2005 or 2006. The Veteran also asserted that he did not have a hip or back disability during service, and that his primary contention was that his service connected right knee disability had caused his right hip and back problems. Following the hearing, the Board remanded the Veteran's claim for an additional VA examination, which was provided in March 2013. The examiner reviewed the Veteran's claims file and examined the Veteran. He then opined that it was less likely than not that the Veteran's lower back and/or right hip disabilities were incurred in or caused by his in-service injury. The examiner explained that orthopedic literature disputes the suggestion that an injured lower limb with normal extension produces an overload and therefore injury to the opposite normal limb or the lower back. There was no overload, even in such situations of compromise as when the injured limb is post polio or amputation with rosthesis, unless there is a contracture of the bad knee or injuries to the good knee from repetitive falls from the bad knee giving way, which was not the disability picture presented in the Veteran's case. Additionally, the examiner noted that the Veteran had a normal gait since his right knee problems were mild. The examiner diagnosed the Veteran with mild degenerative disc disease/degenerative joint disease in his back which was better than age typical. The Veteran was noted to have first been seen for his back in approximately 1996, but had not fallen as a result of his right knee. The examiner diagnosed the Veteran with mild degenerative joint disease in his right hip that was better than age typical. An addendum opinion was provided in August 2013, which stated that the opinion regarding secondary service connection also applied to aggravation, in that the evidence did not show any aggravation of the back or hip in this case. Again, the Board is faced with parsing the probative value of the multiple medical opinions of record in this case. As discussed, the Veteran has submitted several positive opinions from Dr. E., Dr. O. and Dr. D., which link his right hip and back disabilities to his service connected right knee disability. As discussed, Dr. O.'s opinions are of little value given their inconsistency and his demonstrated lack of familiarity with the Veteran's medical history. Predominantly, the negative opinions that have been provided by VA doctors have attributed the degenerative joint disease in the Veteran's hip and back to his age, while the private opinions have suggested that the Veteran's right knee disability resulted in an altered gait which ultimately caused the hip and back problems. Dr. D. wrote in 2008 that the Veteran sustained a right knee injury in 1952 or 1953 while on active duty and had experienced lower back and bilateral hip pain for the previous five years, which would place the onset of back and knee pain in approximately 2003. However, it is clearly documented in the record from Dr. E.'s statements that the Veteran was in fact complaining of back and hip pain much earlier, as it is documented in February 1995 the Veteran was seen with complaints of increased difficulty walking due to pain in his lower back, right hip and right knee. It does not appear that Dr. D. ever had access to the Veteran's claims file (which is not required, but must be considered). Moreover, to the extent that he relied on the Veteran's statements as to medical history, the fact remains that the Veteran does not appear to be a reliable historian. For example, at his hearing before the Board in April 2012 the Veteran's representative asked him when he developed his hip and back problems, to which he asserted that he had experienced them for 6-7 years, since 2005 or 2006. The Board is not suggesting that the Veteran is intentionally trying to mislead VA, it is simply sometimes difficult to recall dates. However, the fact remains that the Veteran was seeking private treatment for hip and back problems more than a decade earlier than he alleged at his hearing. Given this inconsistency, the Board finds that the Veteran's reports of timing are not accurate. Thus, because Dr. D. presumably relied on the Veteran's reports of medical history in rendering his opinion, and because his basic timing is clearly shown to be inaccurate, there is limited probative value found in his opinion. See Miller v. West, 11 Vet. App. 345, 348 (1998) (a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). This opinion is also weakened, because it relies on a finding of an abnormal gait, which is called into question below. Turning to Dr. E.'s opinions, the Board acknowledges that Dr. E. has been treating the Veteran for the longest period of time, since approximately 1991. Additionally, while Dr. E. does not appear to have been privy to the Veteran's claims file, he was apparently shown the Veteran's service treatment records and a previous Board decision. Dr. E. has written nexus opinion letters for the Veteran on four occasions (May 2000, July 2001, January 2003, and August 2008). In his first opinion, he stated that the Veteran's back and hip arthritis was caused by the arthritis in his right knee; in his second opinion he changed gears, suggesting that the Veteran's back pain was the result of his original injury while in service; Dr. E. then reverted back to attributing the cause of the Veteran's back and hip problems to his right knee disability in his third and fourth opinions. Of the four opinions, only the fourth contained any rationale, as Dr. E. stated in that opinion that it was his belief that the Veteran had dealt with an altered walking gait, off and on since 1954 and that the limp was more likely the cause of the mild to moderate back and hip disabilities. Dr. E. added that there was no link other than his knee injury. However, while Dr. E. stated that he believed that the Veteran had dealt with an altered gait since 1954, he did not actually provide any citations to the evidence of record to support his belief. It is true that Dr. E. has treated the Veteran for a number of year, but he did not begin treating the Veteran until 1991, nearly 40 years after separation from service, and he does not appear to have had access to any treatment records for the Veteran during that time. For example, at a VA examination in September 1960, it was noted that the Veteran walked "quite normally." Moreover, when Dr. E. started treating the Veteran in 1991, the Veteran was experiencing right knee pain, but he had full range of right knee motion per a September 1991 treatment record. Additionally, there was no mention of any altered gait, and x-rays showed only mild degenerative changes. It was also noted that the Veteran was on his feet a great deal of time as a realtor. At a VA examination in July 2001, the examiner noted that the Veteran did not limp when ambulating. The examiner in February 2002 also stated that the Veteran walked without a limp. This is consistent with the Veteran's testimony that he started limping around 2002 or 2003. However, if the limping did not begin until 2002, and the limping caused the degenerative joint disease in the Veteran's back and spine, then it would not follow that the degenerative joint disease in his back and hip was detected in approximately 1995 or earlier, as is shown by the evidence of record. For example, the Veteran's wife in October 2001 wrote a letter indicating that he had been experiencing constant pain in his right hip and back for the previous two years, and private treatment records from as early as 1991 showed hip and back pain. That is, the Veteran was clearly experiencing pain prior to the onset of his alleged limp, which does not conform to the Veteran's theory as to why he has this problem. Yet, even at subsequent examinations, a limp was not seen. For example, the VA examiner in April 2004 noted that the Veteran had a normal gait. The Veteran reported at his April 2004 examination that walking actually made both his hip and back feel better, which would seem to conflict with the assertion that limping was causing his degenerative joint disease. The examiner even noted that the Veteran did not have any history of significant lurging gait as would be expected with unusual strains on the hips and the low back. At his hearing, the Veteran testified that even when the VA examiners found no limp, he did actually have a limp. However, such a statement is difficult to square with his other testimony that his limp began in approximately 2002-2003. Closely scrutinizing the evidence in this case raises significant questions about Dr. E.'s opinion, as the rationale for his opinion is based solely on the presence of an abnormal gait for 50 plus years which is simply not shown in the record. As noted, the Veteran was observed to have a normal gait for many years. Alternatively, accepting the Veteran's own testimony as to the onset of his limp as factual, the limp would not have begun until 2002, which is well after the onset of the degenerative joint disease in his back and right hip. Dr. E. and the other private doctors also failed to address the role of aging in the Veteran's development of degenerative joint disease in his back and right hip. This is highly relevant in that the VA examiner in March 2013 observed that the degenerative joint disease in the Veteran's back and hip was actually better than age typical. Dr. E. and the other private doctors also failed to address the fact that orthopedic literature, as explained by the VA examiner in 2013, disputes the suggestion that an injured lower limb with normal extension produces an overload and therefore injury to the opposite normal limb or the lower back. The examiner noted that even in extreme cases of compromise as when the injured limb is post polio or amputation with rosthesis, there was no overload unless there was a contracture of the bad knee or injuries to the good knee from repetitive falls from the bad knee giving way, which was not the disability picture presented in the Veteran's case. Instead, the Veteran was noted to have good range of motion in his right knee in the years before arthritis was discovered (such as at a September 1991 VA treatment record). As such, to the extent the private medical opinions are considered competent evidence, they are entitled to considerably less weight than the opinions of the VA examiners who reviewed the medical literature on the possible relationship between a knee disability and a subsequent back and/or hip disability, but found that the scenarios found in the literature did not fit the Veteran's disability picture and symptomatology. As such, the VA opinions, particularly the most recent opinion, is the most probative evidence and it is therefore entitled to the greatest weight. Given this conclusion, the evidence of record makes it less likely than not that the Veteran's right knee disability caused the degenerative joint disease in either his back or in his right hip. Not only does the evidence show that the degenerative joint disease in the Veteran's back and hip was not caused by his service connected right knee disability, but the evidence of record also fails to show that the degenerative joint disease was aggravated by his right knee. As was explained in an August 2013 addendum to the March 2013 VA examination report, the examiner stated that the opinion regarding secondary service connection also applied to aggravation, in that the evidence did not show any aggravation of the back or hip in this case. Essentially, as discussed above, the most probative medical evidence concluded that there was no relationship between the right knee disability and the development of the Veteran's back and/or right hip disabilities, and therefore because there was not any relationship, the right knee could not aggravate, or at least in this case, did not aggravate his back or right hip. There is no opinion which questions this conclusion as to aggravation. Accordingly, the Veteran's claim is denied. II. Duties to Notify and Assist Under applicable criteria, VA has certain notice and assistance obligations to claimants. See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). In the present case, required notice was provided by a letter dated in December 2008, which informed the Veteran of all the elements required by the Pelegrini II Court as stated above. The letter also informed him how disability ratings and effective dates were established. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). The Veteran has neither alleged, nor demonstrated, any prejudice with regard to the content or timing of VA's notices or other development. See Shinseki v. Sanders, 129 U.S. 1696 (2009). Thus, adjudication of his claim at this time is warranted. As to VA's duty to assist, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Service treatment records, private treatment records, and VA treatment records have all been obtained. Additionally, the Veteran testified at a hearing before the Board. The Veteran was also provided with several VA examinations (the reports of which have been associated with the claims file). The Board finds the most recent VA examination was thorough and adequate and provides a sound basis upon which to base a decision with regard to the Veteran's claim. The VA examiner personally interviewed and examined the Veteran, including eliciting a history from him, and provided the information necessary to evaluate his disability. Importantly, neither the Veteran, nor his representative has voiced any disagreement with the adequacy of the most recent VA examination. See Cox v. Nicholson, 20 Vet. App. 563, 569 (2007); see also Rizzo v. Shinseki, 580 F.3d 1288, 1291 (Fed. Cir. 2009) (finding that where a Veteran does not challenge a VA medical expert's competence or qualifications, VA need not affirmatively establish that expert's competency). As described, VA has satisfied its duties to notify and assist, and additional development efforts would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Because VA's duties to notify and assist have been met, there is no prejudice to the Veteran in adjudicating this appeal. ORDER Service connection for right hip and back disabilities, claimed as secondary to service connected arthritis of the right knee, is denied. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs