Citation Nr: 1803116 Decision Date: 01/17/18 Archive Date: 01/29/18 DOCKET NO. 10-13 905A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUE Entitlement to service connection for a bilateral hip disability, to include avascular necrosis of the bilateral hips. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD S. Medina, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1982 to September 1986. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In July 2013, the Veteran testified at a videoconference before the undersigned Veterans Law Judge. A transcript of the hearing is of record. This matter was previously remanded in January 2014 for further development, which has been completed. The Board notes that the Veteran has perfected appeals on the issues of entitlement to compensation under the provisions of 38 U.S.C. § 1151 for right hip replacement surgery with leg length discrepancy and entitlement to service connection for knee, back, and sciatica nerve conditions as secondary to right hip replacement surgery with leg length discrepancy. However, those issues are awaiting the scheduling of a requested Board hearing. As such, they will be the subject of a later Board decision, if in order. FINDING OF FACT The most probative evidence of record indicates that the Veteran's avascular necrosis of the bilateral hips is not related to service. CONCLUSION OF LAW The criteria for establishing service connection for a bilateral hip disability, to include avascular necrosis of the bilateral hips have not been met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. § 3.303 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a chronic condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b); see also Walker v. Shinseki, 708 F.3d 1331, 1340 (Fed. Cir. 2013) (holding that only conditions listed as chronic diseases in 38 C.F.R. § 3.309(a) may be considered for service connection under 38 C.F.R. § 3.303(b)). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate each claim and what the evidence in the claims file shows, or fails to show, with respect to each claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102 (2017); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran contends that during service he did a lot of heavy lifting and that triggered the process that has caused the necrosis in his hips such that service connection is warranted. As an initial matter, the record reflects the Veteran has been diagnosed with avascular necrosis of the bilateral hips. Accordingly, the first criterion for establishing service connection, a current residual disability, has been met for purposes of continuing the analysis. The question becomes whether the disability is related to the Veteran's active duty service. Upon review of the record, however, the Board finds that the preponderance of the evidence is against the Veteran's claims for service connection. The Veteran's service treatment records are silent as to any complaints of, treatment for, or diagnoses of avascular necrosis of the bilateral hips, or for any hip disability for that matter. Following service, the first indication of a hip disability was not until 1999. In this regard, VA treatment records show that in September 1999, the Veteran complained of bilateral hip pain over the past two years, right greater than left. X-rays at that time revealed a collapse of the right femoral head with secondary acetabular changes. The left hip did appear to have some cystic change, with a well-preserved femoral head and no clear collapse was shown. MRI results were also obtained showing narrow changes involving the majority of the weight-bearing segments of the bilateral femoral heads. The Veteran was diagnosed with bilateral avascular necrosis, symptomatically right worse than left. The physician at that time noted that the etiology was unclear, but that it may be related to the Veteran's brief steroid treatments in the past. The physician stated it was more likely that the etiology might just be an example of idiopathic avascular necrosis. Thereafter, in November 1999, the Veteran underwent right total hip arthroplasty. Thus, there is no competent evidence of a hip disability, to include avascular necrosis of the bilateral hips, in service or within one year following discharge from service. Accordingly, in order to warrant service connection, competent evidence linking the current bilateral hip disability with service is required. VA treatment records dated in January 2001, for an eight-week follow-up status post right total hip arthroplasty, note that the Veteran's post-operative course was uncomplicated; however, he did go into alcohol withdrawal and was treated in the intensive care unit. The physician noted in the assessment that the Veteran has a history of Medrol dose pack usage in the past with significant alcohol usage. Further, it was noted that after the interview, the Veteran admitted to continuing back to drinking, even though he stated in the hospital that he was going to quit. In July 2001, VA treatment records show that the Veteran was seen for evaluation of bilateral hip pain. The physician noted that the Veteran had apparently had avascular necrosis secondary to heavy alcohol use in the past. X-rays at that time revealed a well-seated, well-placed right total hip arthroplasty with no evidence of loosening and the left side showed evidence of several avascular necroses with sclerosis and collapse of the head. Per a July 2007 orthopedic consult, the physician noted that medical records and historian abilities, which were suboptimal, revealed that the Veteran does have a history of taking a Medrol dose pack in the past, alcohol abuse, and retroviral medication secondary to his positive HIV status. The physician's impression noted the Veteran with a total hip arthroplasty on the right side in 1999 that was doing quite well and the left hip with severe avascular necrosis, most likely due to the Veteran's HIV retroviral medication and his alcohol abuse. The physician offered the Veteran a total hip arthroplasty for the left side, but the Veteran stated that at the current time, he was not interested in the procedure and would like to wait until he feels that he is mentally ready and can wean himself off of a little bit of alcohol. VA treatment records thereafter include medication management for his bilateral hip pain. The Board acknowledges that no medical examination or opinion was obtained in regards to the claim for service connection. However, there is no competent evidence of a hip disability, to include avascular necrosis of the bilateral hips, in service or competent evidence suggesting a relationship between the Veteran's avascular necrosis of the bilateral hips and service. Indeed, the medical evidence suggests the Veteran's avascular necrosis is likely related to HIV medication and alcohol abuse. Accordingly, the Board finds that VA examination and/or opinion is not necessary to decide the claim. See 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010) (noting that a conclusory lay statement that a current condition is related to service is insufficient to warrant a medical examination because it would "eliminate the carefully drafted statutory standards governing the provision of medical examinations and require the Secretary to provide such examinations in virtually every veteran's disability case"). In summary, there is no competent evidence of avascular necrosis or any hip disability in service or within one year following discharge from service, and there is no competent evidence of record linking the Veteran's current bilateral hip disability with service. Accordingly, the preponderance of the evidence is against the claim and service connection is denied. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert, 1 Vet. App. at 55-56. ORDER Entitlement to service connection for avascular necrosis of the bilateral hips is denied. ____________________________________________ K.A. BANFIELD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs