Citation Nr: 1803167 Decision Date: 01/18/18 Archive Date: 01/29/18 DOCKET NO. 14-20 985 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUE Entitlement to service connection for a right hip disability secondary to service-connected left and right knee disabilities. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A. Fagan, Counsel INTRODUCTION The Veteran served on active duty from January 1973 to March 1976. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Oakland, California. In April 2017, the Veteran testified at a Board videoconference hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. In conjunction with the hearing, the Veteran submitted additional evidence accompanied by a waiver of RO consideration. 38 C.F.R. § 20.1304. FACTUAL FINDINGS, LEGAL CONCLUSIONS, AND REASONS AND BASES The Veteran is seeking service connection for a current right hip disability that he asserts is secondary to service-connected left and right knee disabilities. Following review of the record, the Board finds that service connection for a right hip disability is warranted. Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) an in-service precipitating disease, injury, or event; and (3) a causal relationship, i.e., a nexus, between the current disability and the in-service event. Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Service connection may also be warranted for disability proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). This permits service connection not only for a disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In this case, the record reflects a current right hip disability, including degenerative joint disease and effusion as evidenced on imaging in June 2011 and November 2014. The question that remains, then, is whether that right hip disability was caused or is aggravated by the Veteran's service-connected knee disabilities. Here, various private physicians provided positive nexus opinions in support of the Veteran's claim. For example, in March 2017, two separate physicians, including an orthopedic surgeon, opined that there is over a 50 percent likelihood that the Veteran's right hip degeneration is related to his knee problems. In April 2017, a different physician similarly documented his belief that it was "very likely" that the development of arthritic changes in the Veteran's right hip was related to his knee injuries. Those opinions are consistent with earlier positive private opinions dated in May 2010 and June 2010. In a May 2010 statement, a private physician referenced x-ray findings of lucency in the lateral aspect of the right acetabular roof and mild-to-minimal spurring in the right acetabulum. The physician noted that the findings could be related to the Veteran favoring his left knee. Then, in a June 2010 statement, the physician who also provided the April 2017 opinion above, discussed the x-ray findings and concluded that the Veteran's report of favoring the right lower extremity due to left knee pain was a reasonable explanation for why the Veteran's right hip had more advanced deterioration than the left hip. Significantly, the Board notes that the foregoing private opinions are not wholly inconsistent with the opinion of an August 2009 VA examiner. In this regard, while the examiner declined to provide a positive nexus opinion, the examiner also did not provide a specific negative opinion on secondary service connection. However, the examiner did note that degenerative joint disease of the knees can be a contributing factor to an altered gait, which was notably not observed during examination, and can place undue stress on other joints such as hips, ankles, and back. Such rationale actually supports secondary service connection in the setting of an altered gait. And, the Board points out that the Veteran was shown in the record to walk with an antalgic gait, such as noted in April 2008 or December 2012. Indeed, during March 2011 VA treatment, the Veteran complained of increasing right hip pain, and it was noted that the Veteran's left knee injury and subsequent three surgeries altered his gait and led to chronic bilateral knee and right hip pain. The Board also finds probative that in May 2005, upon initially complaining of his right hip, the Veteran stated that his left knee problem was starting to affect his right hip, complaining of an onset and increase in right hip pain coincident with worsening left and right knee pain. In this regard, an antalgic gait was shown in the record as early as October 1993, and during a January 2003 VA knee examination, the Veteran discussed shifting weight to his right lower extremity to alleviate his left knee pain. Although the Board acknowledges that the private physicians' positive opinions are not flawless, it finds that those opinions, when viewed in the context of the evidence as a whole - to specifically include the Veteran's competent and credible reports of favoring his right lower extremity due to left knee pain, the evidence of an observed antalgic gait, evidence of more severe degenerative changes in the right hip than the left, and statements of the March 2011 VA provider and August 2009 VA examiner supporting an association between altered gait and right hip degenerative changes - are sufficient to decide the claim. 38 C.F.R. § 3.159(c)(4); see also Mariano v. Principi, 17 Vet. App. 305, 312 (2003) (VA may not seek an additional medical opinion where favorable evidence in the record is unrefuted, and it is not permissible to undertake further development if the purpose is to obtain evidence against an appellant's claim). And, even considering that two VA providers declined to provide a nexus opinion in March 2017, stating that there was no medical evidence to support a relationship, the Board finds that the evidence is at least in relative equipoise. Therefore, resolving all doubt in the Veteran's favor, the Board finds that service connection for a right hip disability is warranted as secondary to a service-connected knee disability. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310. ORDER Service connection for a right hip disability as secondary to a service-connected knee disability is granted. ____________________________________________ S. C. KREMBS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs