Citation Nr: 18142379 Decision Date: 10/15/18 Archive Date: 10/15/18 DOCKET NO. 16-52 301 DATE: October 15, 2018 ORDER Service connection for a left hip disorder as secondary to service-connected right knee disability is denied. Service connection for a back disorder as secondary to service-connected right knee disability is denied. FINDINGS OF FACT 1. A left hip disorder is not caused or aggravated by the Veteran’s service-connected right knee disability. 2. A back disorder is not caused or aggravated by the Veteran’s service-connected right knee disability. CONCLUSIONS OF LAW 1. The criteria for service connection for a left hip disorder as secondary to service-connected right knee disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for service connection for a back disorder as secondary to service-connected right knee disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from June 1948 to July 1952. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a December 2014 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In June 2017, the Veteran and his son testified at a Board hearing before the undersigned Veterans Law Judge. A transcript is of record. In September 2017, the Board remanded the issues listed on the title page, as well as a claim for service connection for a right hip disorder as secondary to service-connected right knee disability, for additional development. In a July 2018 rating decision, the Agency of Original Jurisdiction (AOJ) granted service connection for status post right hip interocanterteric femur fracture with scar. As such is a full grant to the benefit sought with respect to this issue, this matter is no longer before the Board for consideration. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1977). The remaining issues now return for further appellate review. 1. Entitlement to service connection for a left hip disorder as secondary to service-connected right knee disability. 2. Entitlement to service connection for a back disorder as secondary to service-connected right knee disability. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Further, service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310(b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). As an initial matter, the Board notes that the evidence does not show, and the Veteran does not contend, that his left hip and/or back disorders had their onset during service, within one year of his service discharge, or are related to any aspect of his military service. The Veteran also does not contend that he had a continuity of symptoms related to such disorders since service. See Robinson v. Shinseki, 557 F.3d 1355, 1361 (2008) (claims which have no support in the record need not be considered by the Board as the Board is not obligated to considered “all possible” substantive theories of recovery. Where a fully developed record is presented to the Board with no evidentiary support for a particular theory of recovery, there is no reason for the Board to address or consider such a theory). Rather, the Veteran contends that his left hip and back disorders are caused or aggravated by his service-connected right knee disability, to include as the result of falls caused by such disability. In this regard, during the June 2017 Board hearing, the Veteran’s son testified that the Veteran had been using a walker to keep his balance, primarily because he could not bend his knees to walk and his heel gets caught on things so he stumbles and falls; however, with the walker, he could at least catch himself. Additionally, the Veteran testified that as a result of his falls, he had pain in his hips and back. In this regard, the Board finds that the evidence of record confirms that the Veteran has a current diagnosis of left hip and back disorders. Specifically, in conjunction with his October 2014 VA examinations, as well as during treatment, the Veteran was noted to have compression fractures of the thoracic spine; degenerative changes of the thoracic spine; degenerative joint and disc disease of the lumbar spine; severe generalized osteopenia of the lumbar spine; mild osteoarthritis of the left hip, and nondisplaced left greater trochanter fracture, healed. Furthermore, the Veteran is currently service-connected for a right knee disability, currently characterized as status post right knee total arthroplasty. Thus, the remaining question is whether the Veteran’s left hip and back disorders are caused or aggravated by his service-connected right knee disability. As noted in the September 2017 Board remand, April 2013 and October 2014 VA examiners opined that the Veteran’s left hip and back disorders were less likely than not proximately due to or the result of his service-connected right knee disability. However, neither examiner addressed whether his service-connected right knee disability aggravated his left hip or back disorders. Furthermore, while June 2017 VA and private physicians found that the Veteran’s right knee post-surgical issues caused and/or contributed to his falls, they found that his nonservice-connected left knee and bilateral hip disorders also played a role in such falls, and did not specifically address whether the falls resulted in his current left hip and back disorders. Consequently, the Board found such opinions to be inadequate to decide the instant claims and remanded the case in order to obtain an addendum opinion addressing the etiology of the Veteran’s left hip and back disorders. In offering such opinion, the Board requested that the examiner consider the June 2017 VA and private physicians’ opinions, and a February 2014 treatment record reflecting that the Veteran fractured his left hip as a result of a fall. In a November 2017 addendum opinion, the VA examiner reported that the statement provided by a VA physician in June 2017 was rendered by a provider who had never seen the Veteran prior to such visit and a review of such visit did not reflect that the physician did any type of chart review of either VA medical visits from May 1998 to June 2017, or from outside providers. She further reported that such medical entry did not document any specifics in regard to the Veteran’s specific health issues. Consequently, the examiner determined that the June 2017 VA physician’s statement was based solely on the verbal report provided by the Veteran and his son as opposed to any evidence-based medical findings or analysis of the Veteran’s extensive and complex medical history. The VA examiner further found that the June 2017 private physician’s statement similarly did not reflect any extensive review of the Veteran’s protracted and complicated orthopedic, as well as chronic illness, conditions; but rather primarily focused on his prior bilateral knee replacements. She further indicated that such statement primarily discussed the Veteran’s difficulty walking and his frequent falls; however, it was not based on any evidence-based medicine findings and was a conjecture opinion (an opinion or conclusion formed on the basis of incomplete information). Therefore, the examiner concluded that neither of the above-mentioned statements incorporated other factors that may have contributed to the fractures in the Veteran’s hips, but simply gave unsupported statements based on subjective history reports by the Veteran and his son, and their own conjectures regarding the Veteran’s affected gait by his right knee disability. Furthermore, the November 2017 VA examiner found that the Veteran’s mild osteoarthritis of the left hip, which clearly and unmistakably existed prior to service, was not aggravated beyond its natural progression by an in-service event, injury, or illness. As rationale for the opinion, the examiner indicated that the onset of the Veteran’s left hip osteoarthritis was in December 2012 and there were no hip complaints noted prior to such date. She further found that it was more likely than not that his left hip osteoarthritis was due to the normal aging process as he was 84 in December 2012 and was a bricklayer for 30 years, which could also be a factor in the development of hip arthritis. The examiner further indicated that, although an altered gait secondary to right knee degenerative joint disease and leg length discrepancy are factors that alone could cause mild degenerative changes, there are additional factors of normal aging process and occupational history of the Veteran post-discharge that contributed to the development of mild arthritis. The examiner reported that it did not seem likely that the Veteran’s right knee disability aggravated his left hip osteoarthritis as mild arthritis in an individual over 80 years old was a common diagnosis of that age group. She further indicated that the fact that mild arthritis was present in the same degree in both hips would lend support that the Veteran’s right knee disability did not aggravate such in either hip as it would be more likely than not to see a degree of difference in degenerative changes in the contralateral side (left hip) compared to the right hip. The November 2017 VA examiner found that the nondisplaced left greater trochanter fracture, which clearly and unmistakably existed prior to service, was not aggravated beyond its natural progression by an in-service event, injury, or illness. As rationale for the opinion, the examiner reported that a review of the medical records indicated that such disorder occurred after the Veteran slipped in the snow and sustained a mechanical fall. Here, the examiner explained that an external environmental factor was the causative factor (snow on the ground) that resulted in the Veteran’s limping due to the icy surface of the ground he was walking on and, due to the fact there was an external environmental factor, the Veteran’s right knee disability was not the causative factor nor did it aggravate the left hip fracture that occurred due to such fall in February 2014. The examiner further explained that there was no indication that the Veteran’s fall was due to an inability to bend his right knee or that his left leg was now longer and he had a significant loss of balance which caused him to fall. The examiner noted that slipping on an icy surface could occur to healthy, young individuals (children to adults) without any lower extremity dysfunction. The November 2017 VA examiner found that the Veteran’s compression fractures of the thoracic spine, which clearly and unmistakably existed prior to service, was not aggravated beyond its natural progression by an in-service event, injury, or illness. As rationale for the opinion, the examiner indicated that, although there were multiple factors associated with the Veteran’s compression fractures, to include: (1) the Veteran’s fall was secondary to syncopal event from orthostatic hypotension; (2) at the time of the fall, the Veteran had well-documented osteoporosis of the thoracolumbar spine dating back to April 2011, which preceded his fall; and (3) a December 2011 treatment record notes that the Veteran was seen for balance retraining for syncope, collapse, and abnormal gait. The examiner further indicated that the primary cause of the Veteran’s fall that led to the compression fractures of his thoracic spine was a syncopal event from orthostatic hypotension, and such disorder was not causally related to the Veteran’s right knee disability nor did the right knee disability aggravate the compression fractures. The examiner concluded that, without the inciting event of the syncopal episode, the fall would not have occurred and the Veteran would not have sustained fractures to his thoracic spine. The November 2017 VA examiner found that the Veteran’s degenerative changes of the thoracic spine and degenerative joint and disc disease of the lumbar spine, which clearly and unmistakably existed prior to service, was not aggravated beyond its natural progression by an in-service event, injury, or illness. As rationale for the opinion, the examiner indicated that it was more likely than not that the Veteran’s degenerative changes in the spine was due to the normal aging process and he was a bricklayer for 30 years, which could also be a factor in the development of spine arthritis. The examiner further indicated that spinal arthritis could be caused by many factors; however, the most common cause was the natural degeneration process of the spine with age. The examiner reported that, while spinal arthritis was a common development later in life, there were several factors that could increase an individual’s risk of developing the condition, such as: age, gender, injury, heredity, and obesity. Here, the examiner explained that there was no evidence that pathology or mechanical dysfunction of the Veteran’s right knee led to dysfunction or pathology of the thoracic or lumbar spine as the altered mechanics or forces were not significant enough to cause such pathology of the spine. The examiner further explained that there was no evidence that the Veteran’s right knee disability aggravated his thoracic or lumbar spine arthritis. Finally, the November 2017 VA examiner found that the Veteran’s severe generalized osteopenia of the thoracic spine, which clearly and unmistakably existed prior to service, was not aggravated beyond its natural progression by an in-service event, injury, or illness. As rationale for the opinion, the examiner reported that osteopenia referred to bone mass that was lower than an individual’s peak bone mass, but not yet low enough to be considered osteoporosis. The examiner further reported that risk factors for osteopenia included: family history of osteoporosis, previous low-impact bone fracture, smoking, rheumatoid arthritis, Asian descent, thin body habitus, corticosteroid usage, low estrogen in women, low testosterone in men, malabsorption conditions, and regular alcohol intake. Here, the examiner explained that the Veteran’s right knee disability had no causal relationship to osteopenia. The examiner further explained that osteopenia was a distinct etiology that was not related to or was aggravated by the Veteran’s right knee disability. In this regard, the Board finds that it is clear from the examiner’s rationales that she determined that the Veteran’s left hip and back disorders were less likely than not proximately due to, the result of, or aggravated by the Veteran’s service-connected right knee disability. Therefore, the examiner’s selections of preprinted language with respect to pre-existing disabilities were no more than meaningless errors in selecting the intended options. The Board places great probative weight on the November 2017 VA examiner’s opinions that the Veteran’s left hip and back disorders were not caused or aggravated by his service-connected right knee disability. Specifically, such opinions considered all of the pertinent evidence of record, and provided detailed rationales for the conclusions reached, relying on and citing to the records reviewed. Moreover, the examiner offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez, supra; Stefl, supra. The Veteran has not submitted medical evidence to refute the November 2017 VA opinions or otherwise diminish their probative weight. The Board has also considered the Veteran’s and his son’s statements in support of his claims. In this regard, while both of them are competent to report what they have witnessed, such as falls, they are not competent to offer an opinion as to whether his right knee disability caused or aggravated his left hip and/or back disorder, to include as a result of a fall, since they do not possess the requisite medical knowledge to offer such an opinion. Specifically, the etiology of the Veteran’s left hip and back disorders, to include whether such are related to his right knee disability, involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. Therefore, as such is a complex medical question, neither the Veteran nor his son are competent to offer an opinion as to the etiology his left hip and/or back disorder, and, consequently, their opinions on such matter are afforded no probative weight. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Therefore, based on the foregoing, the Board finds that the Veteran’s left hip and back disorders are not caused or aggravated by his service-connected right knee disability. Consequently, service connection for such disorders is not warranted. In reaching such decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claims for entitlement to service connection for left hip and back disorders. As such, that doctrine is not applicable in the instant appeal, and his claims must be denied. 8 U.S.C. 5107; 38 C.F.R. 3.102; Gilbert, supra. A. JAEGER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Koria B. Stanton, Associate Counsel