Citation Nr: 1638592 Decision Date: 09/29/16 Archive Date: 10/13/16 DOCKET NO. 13-26 884 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES 1. Entitlement to service connection for a right leg disorder. 2. Entitlement to service connection for a low back disorder, claimed as secondary to a right leg disorder. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD D. Van Wambeke, Counsel INTRODUCTION The Veteran had honorable active duty service from October 1967 to October 1969. These matters come to the Board of Veterans' Appeals (Board) on appeal from a September 2012 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran requested a hearing before the Board in his September 2013 VA Form 9. The RO informed the Veteran that his requested hearing had been scheduled for September 2014. The Veteran, however, failed to report for the scheduled hearing. As the record does not indicate the Veteran has requested that the hearing be rescheduled, the Board deems the Veteran's request for a hearing to be withdrawn. 38 C.F.R. § 20.704 (2015). The current record before the Board consists entirely of electronic files known as Virtual VA and the Veterans Benefits Management System (VBMS). FINDINGS OF FACT 1. There is clear and unmistakable evidence showing that the Veteran had a right leg condition that preexisted his period of active duty service. 2. The preexisting right leg condition was temporarily aggravated during service, but in-service surgery ameliorated the condition incurred before enlistment and there is clear and unmistakable evidence showing that the Veteran's right leg condition was not aggravated by service and that both the post-service avascular necrosis of the right hip and the right hip replacement were the natural progression of the pre-military bone fracture requiring three surgeries prior to service. 3. There is no probative evidence establishing that the Veteran's current low back disorder had its onset during active duty service or is related to such service, or that a chronic back disability manifested within one year of the Veteran's October 1969 discharge from service. 4. Service connection for a right leg disorder is being denied such that service connection for a low back disorder as secondary to any right leg disorder is impossible. CONCLUSIONS OF LAW 1. The criteria for service connection for a right leg disorder have not been met. 38 U.S.C.A. §§ 1110, 1111 (West 2014); 38 C.F.R. §§ 3.303, 3.304 (2015). 2. The criteria for service connection for a low back disorder have not been met. 38 U.S.C.A. § 1110 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA has a duty to notify and assist a claimant in the development of a claim. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2015). VA must notify a claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2015). Compliant notice was provided in June 2012. In addition, the Board finds that the duty to assist a claimant has been satisfied. The Veteran's service treatment records are on file, as are various post-service medical records. A VA examination has been conducted and an opinion obtained. After a careful review of the file, 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 Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C.A. § 1110. 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). To establish service connection for a disability resulting from a disease or injury incurred in service, or to establish service connection based on aggravation in service of a disease or injury which pre-existed service, there must be (1) competent evidence of the current existence of the disability for which service connection is being claimed; (2) competent evidence of incurrence or aggravation of a disease or injury in active service; and (3) competent evidence of a nexus or connection between the current disability and the disease or injury incurred or aggravated in service. Horn v. Shinseki, 25 Vet. App. 231, 236 (2010); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009); cf. Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). In many cases, medical evidence is required to meet the requirement that the evidence be "competent." However, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). For certain chronic disorders, such as arthritis, service connection may be granted on a presumptive basis if the disease is manifested to a compensable degree within one year following service discharge. 38 U.S.C.A. §§ 1101, 1112 (West 2014); 38 C.F.R. §§ 3.307, 3.309 (2015). VA regulations provide that 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 examination, acceptance, and enrollment. 38 C.F.R. § 3.304(b) (2015). Before the presumption of soundness can be applied, there must be evidence that a disability or injury that was not noted on entrance into service manifested or was incurred in service. See Gilbert v. Shinseki, 26 Vet. App. 48, 52 (2012). Where there is evidence showing that a disorder manifested or was incurred in service, and this disorder is not noted on the Veteran's entrance examination report, the presumption of soundness operates to shield the Veteran from any finding that the unnoted disease or injury preexisted service. Id. To rebut the presumption of sound condition, VA must show by clear and unmistakable evidence (1) that the disease or injury existed prior to service, and (2) that the disease or injury was not aggravated by service. Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). To satisfy the second requirement for rebutting the presumption of soundness, the government must show, by clear and unmistakable evidence, either that (1) there was no increase in disability during service, or that (2) any increase in disability was "due to the natural progression" of the condition. Joyce v. Nicholson, 443 F.3d 845 (Fed. Cir. 2006). The claimant is not required to show that the disease or injury increased in severity during service before VA meets both of these burdens. See VAOPGCPREC 3-2003. Service connection may be granted on a secondary basis for a disability that is proximately due to or the result of an established service-connected disorder. 38 C.F.R. § 3.310(a) (2015). Similarly, any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. 38 C.F.R. § 3.310(b) (2015); Allen v. Brown, 7 Vet. App. 439 (1995). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C.A. § 5107(b). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. See Gilbert, 1 Vet. App. at 54. The Veteran seeks entitlement to service connection for disorders of the right leg and low back. He asserts that he sustained an injury to his right leg during service in October 1968 and that he began to have lower back problems in October 2000. See VA Form 21-526 received May 2012. In an October 2012 VA Form 21-4138, the Veteran clarified that both conditions were the result of military training. He reported that he sustained an original injury before military service and that it was his belief he should never have been inducted. The Veteran asserted that after induction, his training caused the rod in his right leg to shift and move, which led to surgery, and that he was having problems with his back as a result of favoring certain walking positions, which had caused deterioration in his upper and lower back. In a VA Form 9 received in September 2013, the Veteran reported that his original injury, a broken right femur, was treated before military service; that he was drafted and denied entry due to the leg injury; that on a second draft notice, he was inducted and in time, the training caused re-injury to his leg, which in time affected his lower back, knee and hip due to favoring the original injury and re-injury from training. Service treatment records reveal that a March 31, 1964, letter from Dr. J.S. reported that the Veteran had been treated intermittently the past four years; that he had sustained a fracture of the femur in 1959, which failed to heal and required insertion of a plate; that after two years there was still no healing and an intramedullary pin was inserted; and that after about eight months, healing at the fracture site was complete. It was also noted that the pin was still present and should be removed in the near future; that motion was complete and painless; and that the Veteran had been working the past four years. A May 21, 1965, letter from Dr. K.A.F. reported that the Veteran had an intramedullary rod in his right thigh secondary to a fracture and bone graft and would need this removed at some time in the future. It was also noted that the Veteran was still under this physician's care and treatment. During a July 1967 pre-induction examination, a fracture of the right femur with intramedullary pin in place (six years) was noted. It was also noted that he had been rejected from AFES in 1964 for above diagnosis. The only defect or diagnosis listed was defective hearing. The Veteran was found fit for military service in October 1967. In an October 10, 1967, letter from Dr. R.B.C., it was reported that the Veteran had fractured his right femur in 1960 and again in 1961, requiring three surgical procedures, the last being insertion of an intramedullary rod by an orthopedic surgeon, who had recommended that the rod be taken out. It was reported that the Veteran had not had the rod removed as of the date of the letter. It was noted that the Veteran complained of soreness and stiffness in his right hip, made worse by lifting, excess use and in cold weather; that he was unable to run without experiencing considerable pain in his hip; and had only been able to run for a short distance. It was Dr. C's opinion that the Veteran could not withstand intensive training required for the military until he had the recommended surgery on his right leg, which he assumed was simply removal of the intramedullary rod. The Veteran was found not to be medically qualified for full duty on October 27, 1967, due to previous fracture at right hip (has pin in it - can't function). See DA Form 8-274. A health record dated on that same date indicates that the Veteran was seen with complaint of pain and inability to perform in active basic training due to a pin in his right hip from a fracture of the femur. An x-ray of the right hip was ordered and a consult to the orthopedic clinic was requested. The Veteran was seen on November 1, 1967, with complaint as before with a notation that the orthopedic consult had not been done. A November 8, 1967, health record documents that the Veteran reported twisting his leg on the rifle range the day before and now had pain in his right hip and upper femur. Examination revealed tenderness at the scar site on the hip and along the lateral femur. Passive range of motion was full. A November 14, 1967, x-ray of the right leg showed a well-healed fracture of the mid-shaft of the right femur traversed by an intramedullary nail. In a December 20, 1967, letter, the Veteran's congressman requested that arrangements be made to have the Veteran be given a complete and thorough examination, including examination by an orthopedic surgeon, soon after he reported to his new duty station to determine if he should be discharged on account of disability. The congressman reported that as a physician, it was his opinion that the Veteran was not physically qualified for military service and should not have been inducted into the army. The congressman reported that he had been advised that the Veteran experienced a great deal of difficulty during basic training, but made no complaint, and that even though he was supposed to have been assigned to limited duties for training, he had had to undergo rigorous training and exercises and that he had been unable to consult an orthopedic surgeon on account of his training schedule. In response to the congressional injury, the commanding colonel reported that the Veteran was examined on January 12, 1968, in the orthopedic clinic with complaint of hip and thigh pain resulting from fracture right femur at junction of distal and middle third (1961) with bone graft and intramedullary rod. Examining physician was of the opinion that the hip pain was probably related to the formation of a bursa around the intramedullary rod head and was of the opinion that removal of the rod would improve the hip pain. Examination indicated the fracture to be well healed; therefore, there was no medical reason to leave the rod in. The Veteran, however, stated that he did not desire to undergo surgery for the removal of the rod. He was physically fit for military duty with permanent L-3 profile with limitations of no crawling, stooping, running, jumping, prolonged standing or marching. The physician did not think removal of the rod would improve the thigh pain, but this seemed less troublesome than the hip pain. The January 12, 1968, health record is also of record. A January 12, 1968, x-ray of the right femur showed a healed fracture site in the mid-femoral shaft with a metallic rod through the entire shaft of the femur. Position and alignment of fragments were excellent. The Veteran was returned to his unit for duty and was found medically qualified for duty with limitations in January 1968. The defect was old fracture right femur with intramedullary rod and the Veteran was not to crawl, stoop, run, jump, do any prolonged standing, or march. See DA Form 8-274. The Veteran was seen on May 27, 1968, with complaint of pain in the right thigh, more bothersome than right hip. Subsequent health records are difficult to read. The Veteran was seen for orthopedic consult on March 20, 1969. It was noted that he had had approximately one week of pain and tenderness in the right hip area and orthopedics was requested to evaluate the Veteran as to whether the pin was the cause of the present problem. It appears the assessment was healed fracture right femur with intramedullary rod in place and that the Veteran was to be admitted with the same diagnosis. An x-ray of the right hip taken March 21, 1969, showed a nail extended some two centimeters above the trochanter without calcification about it. The Veteran was admitted on April 9, 1969, with a diagnosis of old fracture right femur. "Past history revealed that in 1962, he fractured his femur in a farm accident which was treated with a metal plate. Six months later he accidentally refractured the same area. The plate was reinforced. Eight to ten months later and finally because of instability of the plate, an intramedullary rod was passed and a bone graft performed. Subsequently he has had intermittent right hip and anterior thigh dull aching pain, particularly after prolonged standing and walking. The symptoms have gradually gotten worse." On review of systems, the Veteran complained of a nagging low back pain without radiation for the past year. The Veteran underwent uncomplicated removal of the intramedullary rod in the right femur on April 11, 1969, and was discharged on April 21, 1969, and was found ready to return to full duty. At the time of a separation examination conducted in August 1969, the Veteran reported cramps in his legs, lameness, and recurrent back pain. He noted that he had had a right leg operation to remove a pin that had been put there about six years before; and that he had back pain because of shortness of muscles in the right leg. The examiner indicated that the Veteran had fractured his right femur in 1962 in a farm accident and that he was treated with a metal plate but refractured it accidentally six months later and the plate was reinforced with an intramedullary rod and bone graft performed eight to 10 months later because of unstable metal plate. The examiner also noted that the Veteran underwent uncomplicated removal of the intramedullary rod in April 1969 because of symptomatic right hip and back pain. No other notations were made. The post-service evidence in this case includes private treatment records and a VA examination report. The Board notes that the pertinent private treatment records all pre-date the date the claim was initiated, but will discuss those most salient to the claim. The Veteran was seen in April 1998 with complaint of seven to eight year history of right hip and right knee pain. All the right hip problems reportedly dated back to when a tractor ran over his right leg as a teenager and he required multiple operations on his right leg, including insertion and removal of an intramedullary rod. The Veteran was unsure whether the right knee pain was a separate issue or whether it was a pain radiating from his right hip. The Veteran reported he had been told he had bad arthritis of his hip and would someday need a replacement. X-rays of the hip revealed fairly advanced degenerative joint disease; x-rays of the right knee showed mild medial joint space narrowing. The diagnoses were avascular necrosis of right hip with moderately advanced arthritis; and possible medial meniscal tear, right knee. A magnetic resonance imaging (MRI) was ordered, which showed degenerative changes about the knee, including some degeneration of the meniscus, but no meniscal tears. It was noted that this left some doubt as to whether his symptoms were more primarily coming from the knee or from the hip with referred pain. The right knee was injected to help distinguish knee from hip pain. The Veteran was seen with chief complaint of right hip and right knee pain in May 2001. He was diagnosed with severe osteoarthritis of the right hip. X-rays showed his right hip was severely arthritic and the place where he had a femur fracture in the past could be seen. In a May 2001 consult, it was noted that the Veteran had initially done well after the 1965 surgery to remove the hardware, but over the last several years, he had had declining function in his hip. The Veteran underwent a right total hip replacement on June 7, 2001. The Veteran was seen in October 2006 for a five year checkup following his right hip replacement with complaint of right knee pain. X-ray of his right hip showed his components were well fixed with no loosening or wear. Standing x-ray of the right knee showed severe medial compartment arthritis. The Veteran underwent years of right knee injections. The Veteran was seen in March 2010 after two years with complaint of severe right knee pain. It was noted that he had undergone injections and these were no longer helping him. X-rays showed his total hip was in good position and alignment with no loosening and no wear; his right knee showed severe arthritis. The Veteran underwent a right total knee arthroplasty on April 14, 2010. The Veteran underwent a VA hip and thigh conditions Disability Benefits Questionnaire (DBQ) in September 2012. The diagnoses provided were status post fracture right femur with internal fixation times two and replacement of intramedullary rod; status post removal of intramedullary rod and avascular necrosis right hip; status post right hip replacement. It was reported that the Veteran fractured his right femur in a farm tractor accident at age 16, prior to military service. He had a metal plate inserted for the fracture and required a second surgery after reinjuring the femur. He required a rod to aid in bone healing after there was a second fracture. The rod was removed after he was in service. He had chronic pain in the upper leg and thigh prior to service. He says after he was drafted the pain became more intense. He was eventually given a permanent profile. Eventually the rod was removed from his right leg, which he said improved the hip pain. He stated he cannot recall when the pain became worse again after service. After he was discharged from service he worked at his father in law's marina and then worked in the trucking business (driver). He worked off and on as a truck driver for 30 years. He was followed for hip pain by a private family doctor. He took pain meds and had to have hip replacement about 2001 or 2002. The Veteran reported that he still had pain located in the right posterior upper buttock, stating "it goes around to the small of my back" right side. He did not complain of lateral hip pain. The Veteran indicated that he did not have full range of motion of the right hip, but denied flares of hip pain. The Veteran also underwent a VA back conditions DBQ in September 2012, at which time he was diagnosed with degenerative disc disease of the lumbar spine. The Veteran reported that he had had pain in lower back for 30 something years. The pain was located in the right posterior upper buttock and the Veteran reported "it goes around to the small of my back" right side. He denied spine surgery and injuries to his spine. The low back pain used to radiate down the right leg but now radiated into the left thigh and had some numbness in the left distal thigh. The VA examiner conducted a detailed physical examination of the Veteran's right hip/thigh and back and reviewed the evidence of record with discussion of the service treatment and post service treatment records. X-rays contained an impression of degenerative disc disease L5-S1 and mild generalized degenerative changes. The RO had asked the VA examiner to provide an opinion regarding whether the Veteran's right leg condition, which clearly and unmistakably existed prior to service, was aggravated beyond its natural progression by his complaints of or treatment for right leg problems, to include surgery, in service. It was the examiner's opinion that the claimed condition was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. The rationale was based on a note typed by a private physician dated October 10, 1967, that shows that the Veteran had right hip condition prior to military service; and a note written by a private doctor dated April 17, 1998, that stated "This 54 yr old gentleman has had 7 to 8 years of right hip and right knee pain." The examiner indicated that reference to the October 1967 letter was made to show that the Veteran had chronic pain prior to service, which was aggravated by running, lifting, excess use. The examiner noted that service treatment records do show that the Veteran sought care for hip pain such that the record is clear that he had aggravation of his hip pain during service. However, the Veteran himself stated that surgery performed during service to remove the intramedullary rod helped improve his hip pain during the rest of the time he was in military service. He was provided a permanent profile that protected his hip and leg from the rigors of military service even prior to the surgery to remove the rod. The examiner also noted that after service, the Veteran worked for 30 years as a truck driver (He would have repeatedly used the right leg for the clutch). In summary, the examiner stated that there was evidence that there was limited temporary aggravation of the Veteran's chronic hip pain during service, but the Veteran's statement of improved pain after removal of the intramedullary rod shows that the aggravation was rectified by its removal; that post military private medical records show that the Veteran had recurrence of chronic hip pain by the 1990s; that though it may be likely that he had hip pain after service, there are no records showing recurrence of hip pain prior to the 1990s or of pain to the degree that required medical care or hip replacement prior to 1998 (more than 20 years after he was discharged from service); that the records from 1998 show that he had developed avascular necrosis of the right hip, which was the likely natural progression of the pre-military bone fracture requiring three surgeries prior to service; and that there was no evidence of avascular necrosis of the right hip during service. The examiner concluded that the Veteran's right hip and leg condition due to fracture was not permanently aggravated by military service; that the condition of the hip requiring hip replacement was the natural progression of the fracture requiring three surgeries that occurred prior to service; and that the aggravation during service was rectified during service by permanent profile and removal of the intramedullary rod. The RO also asked the VA examiner to provide an opinion regarding whether the Veteran's lower back condition was proximately due to or the result of his right leg condition. The examiner reported that review of medical literature showed that the incidence of low back pain at some time in a person's lifetime in the U.S. population is reported to be as high as 90 percent and that the degenerative changes that occur in the intervertebral disc in the spine are thought to be part of the normal process of aging and do not always lead to low back pain. The examiner also reported that review of medical literature showed that the presence of degenerative disc and facet pathology in older adults is ubiquitous regardless of clinical status with greater than 90 percent demonstrating some level of degeneration. It was the VA examiner's opinion that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness. The rationale was that though the Veteran has had chronic right hip pain, there are no records to support a nexus between the low back pain degenerative disc disease L5-S1 or mild generalized degenerative changes and the right femur fracture that occurred at age 16 or to the resultant right avascular necrosis right hip. The examiner stated that the lumbar condition was most likely due to aging. The evidence of record is against a finding that service connection for a right leg disorder is warranted. The Board finds that the presumption of soundness does not attach in this case. 38 U.S.C.A. § 1111 (West 2014); 38 C.F.R. § 3.304(b)(1) (2015); see also Gilbert, 26 Vet. App. at 52; Wagner, 370 F.3d at 1096. Multiple medical statements drafted prior to the Veteran's induction into service clearly reflect the Veteran fractured his right femur and had multiple surgeries to correct the condition prior to service. See March 31, 1964, letter from Dr. J.S.; May 21, 1965, letter from Dr. K.A.F.; October 10, 1967, letter from Dr. R.B.C. Most telling is the letter from Dr. R.B.C., drafted days prior to the Veteran's induction. In that letter, Dr. R.B.C. notes that the Veteran complains of right hip soreness and stiffness, and that he is unable to run without experiencing considerable pain in his hip. The Board finds that the above represents clear and unmistakable evidence of a right leg disability that pre-existed the Veteran's entry into service. The next question is whether there is clear and unmistakable evidence that the pre-existing leg disability was not aggravated by the Veteran's military service. The Board finds that there is. The record demonstrates that the Veteran's pre-existing right leg condition underwent a temporary increase in severity during service; however, the surgery performed on April 11, 1969, clearly and unmistakably reversed the increase in disability as the Veteran was found ready to return to full duty 10 days after the surgery and the Veteran was not seen again with any complaints related to his right leg prior to his October 1969 discharge, in sharp contrast to the numerous times he sought treatment related to his right leg prior to the surgery. The evidence clearly and unmistakably shows that the right leg condition which pre-existed service was not aggravated by the Veteran's military service. While the Board acknowledges that the Veteran reported cramps in his legs and lameness at the time of an August 1969 separation examination, examination of the lower extremities and musculoskeletal system was normal at that time and the complaints do not represent a worsening from the complaints of hip soreness, stiffness, and pain noted days before his entrance into the military. Moreover, the post-service medical evidence represents clear and unmistakable evidence that the pre-existing right hip disability was not aggravated by service. The Board acknowledges the Veteran's assertion that in time, re-injury of his right leg during service affected his knee and hip. See VA Form 9 received in September 2013. Although the Veteran is competent to assert that he had symptoms involving his right leg after service, as a lay person without the appropriate medical training and expertise, he simply is not competent to provide a probative opinion that his pre-existing right leg condition was aggravated by service. See Bostain v. West, 11 Vet. App. 124, 127 (1998), citing Espiritu v. Derwinski, 2 Vet. App. 492 (1992); see also Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"). Moreover, an April 1998 private treatment record documents that the Veteran complained of a seven to eight year history of right hip and knee pain, which would have been in approximately 1990 and is not contemporaneous to the Veteran's October 1969 discharge from active duty service. In addition to the foregoing, the September 2012 VA examiner provided an opinion that the Veteran's right leg condition was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. The examiner explained that the Veteran had stated that the in-service surgery performed to remove the intramedullary rod helped improve his hip pain during the rest of the time he was in military service, which showed that the aggravation manifested by right hip pain during service was rectified by the removal of the intramedullary rod that had been placed prior to service. The examiner also explained that both the post-service avascular necrosis of the right hip and the right hip replacement were the natural progression of the pre-military bone fracture requiring three surgeries prior to service, and that there was no evidence of avascular necrosis of the right hip during service. This opinion, which stands uncontroverted in the record, is afforded high probative weight. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (a factor for assessing the probative value of a medical opinion includes the thoroughness and detail of the opinion). Based on the evidence as a whole, the Board finds that the Veteran's right leg disorder clearly and unmistakably pre-existed service and clearly and unmistakably was not aggravated by his military service. As such, the presumption of soundness is rebutted and the claim for service connection is denied. The preponderance of the evidence of record is also against a finding that service connection for a low back disorder is warranted on a direct basis. While the Board acknowledges that the Veteran reported recurrent back pain at the time of his August 1969 separation examination, he has not asserted that his current back problems began in service. Rather, he reported that he began to have lower back problems in October 2000 when he initiated his claim, see VA Form 21-526 received in May 2012, and in the VA Form 9 received in September 2013, the Veteran indicated that his back was affected "in time" following service. Moreover, none of the post-service medical evidence indicates that the Veteran's low back disorder is related to service. The VA examiner in 2012 found that the Veteran's lumbar condition was most likely due to aging and cited to medical articles in support of the conclusion. In the absence of any probative evidence that the Veteran's current low back disorder had its onset during active duty service or that it is related to such service, the claim for service connection for a low back disorder must be denied on a direct basis. 38 C.F.R. § 3.303. The preponderance of the evidence of record is also against a finding that service connection for a low back disorder is warranted on a presumptive basis. This is so because there is no probative evidence that arthritis of the lumbar spine manifested within one year of the Veteran's October 1969 discharge from service. 38 C.F.R. §§ 3.307, 3.309 (2015). Lastly, the preponderance of the evidence of record is also against a finding that service connection for a low back disorder is warranted on a secondary basis. This is so because the Veteran has asserted that his current low back disorder is secondary to his right leg disorder and service connection for a right leg disorder has been denied in this decision. As such, service connection for a low back disorder as secondary to any right leg disorder is impossible. 38 C.F.R. § 3.310. As the preponderance of the evidence is against the claims, the benefit of the doubt rule is not applicable. 38 U.S.C.A. § 5107(b) (West 2014); 38 C.F.R. § 3.102 (2015). ORDER Service connection for a right leg disorder is denied. Service connection for a low back disorder is denied. ____________________________________________ Nathan Kroes Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs