Citation Nr: 18145644 Decision Date: 10/29/18 Archive Date: 10/29/18 DOCKET NO. 15-04 955 DATE: October 29, 2018 ORDER Entitlement to service connection for a left hip disability is denied. FINDING OF FACT The preponderance of the evidence does not support a finding that a left hip disability was incurred in or aggravated by service or is due to or aggravated by a service-connected disability. CONCLUSION OF LAW The criteria for entitlement to service connection for a left hip disability have not been met. 38 U.S.C. §§ 1110, 1131, 1132, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active military service from September 1974 to November 1977. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a July 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge in July 2018. A transcript of that hearing is of record. Entitlement to service connection for left hip disability Service connection may be granted for disability caused by disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. In order to establish service connection for a claimed disability, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence, generally medical, of a relationship between the claimed in-service disease or injury and the current disability. Hickson v. West, 12 Vet. App. 247 (1999). Service connection may also be granted for any disease initially diagnosed after service, when the evidence establishes that the disease was incurred in service. 38 U.S.C. § 1113(b); 38 C.F.R. § 3.303(d); Cosman v. Principi, 3 Vet. App. 503 (1992). The disease entity for which service connection is sought must be chronic rather than acute and transitory in nature. For the showing of chronic disease in service, a combination of manifestations must exist sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word chronic. Arthritis is among the chronic diseases listed in 38 C.F.R. § 3.309(a), and service connection for arthritis may be established based on a continuity of symptomatology. Service incurrence will be presumed for certain chronic diseases, including arthritis, if manifest to a compensable degree within the year after active service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309. A disability that is proximately due to or the result of a service connected disease or injury shall be service connected. When service connection is established for a secondary disability, the secondary disability shall be considered a part of the original disability. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a non-service connected disability, which is aggravated by a service-connected disability. In that instance, the Veteran is compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b); Allen v. Brown, 7 Vet. App. 439 (1995). The Veteran’s service medical records are negative for signs, symptoms, or complaints of any left hip disability. Medical records indicate that the Veteran first experienced left hip pain in February 1998 and was subsequently diagnosed with bilateral avascular necrosis of the hips. The Veteran has since had both hips replaced. The Veteran contends that service-connected right hip and right knee disabilities are the cause of or aggravated a left hip disability. When there is approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA will resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107(b). However, the Board finds that the evidence in this case is not in relative equipoise with regard to the question of whether the claimed left hip disability is related to the Veteran’s service. To back the contention that the right hip disability is the cause of the left hip disability, the Veteran has provided two opinions. In a June 2015 private opinion, an orthopedic surgeon opined that “the patient having right hip OA can cause pressure on the left hip over time and cause over use arthritis.” That opinion is stated in speculative language. The second opinion is from the Veteran’s private primary care physician, who has been treating the Veteran for over 30 years. In that March 2011 opinion, the primary care physician wrote, the Veteran “underwent a right hip replacement in 1998… for avascular Necrosis of his hip. He has favored that hip and has developed arthritis in his left hip. It has gotten progressively worse and now needs replacement. I feel his left hip problems are directly related to his right hip problem and surgery.” Hearing testimony establishes that the primary care physician had access to the entire file when writing that opinion. It is unclear whether the orthopedic surgeon reviewed the entire claims file prior to providing the opinion. The medical records also contain a December 2008 letter from the surgeon who performed the hip replacement surgery on the Veteran. The surgeon wrote “please be advised that I have recently performed hip replacement surgery on [the Veteran] for end stage arthritis of his left hip which is related to avascular necrosis. He had a similar procedure done for the same reasons in 1998. He was diagnosed with avascular necrosis when he was in the service and has documented bilateral avascular necrosis on imaging studies dating back to 1998. It is my opinion to a reasonable degree of medical certainty that his hip disease is service related and involves both hips.” The Board finds the June 2015 and March 2011 opinions to be both competent and credible. Both the primary care physician and the orthopedic surgeon possess the medical expertise and training needed to deem their opinions on this matter credible and competent. However, the Board assigns little probative weight to the opinions given in both circumstance as little medical reasoning is provided for the opinions provided. The June 2015 opinion is speculative and only a single sentence without rationale or further explanation. In order to be entitled to probative weight, a medical opinion must contain not only clear conclusions with supporting data, but also a reasoned explanation connecting the two. Nieves-Rodrigues v. Peake, 22 Vet. App. (2008). Here, both private medical opinions provide conclusions without supporting data or an explanation. Additionally, as it pertains to the June 2015 opinion, according to hearing testimony, it is unclear if the surgeon reviewed the Veteran’s entire file before writing the opinion, which undermines the basis of the conclusion. In regard to the December 2008 letter, the service medical records do not indicate that the Veteran was diagnosed with avascular necrosis in service or treated for any left hip disability as the surgeon claims. The surgeon’s statement regarding documented evidence of bilateral avascular necrosis on imaging studies dating back to 1998, is not pertinent as the Veteran was not in service in 1998 and that information does not show that the avascular necrosis of the left hip with segmental collapse is secondary to medial collateral ligament strain right knee and/or right hip replacement. The surgeon states that the Veteran’s hip disease is service related, but there is no evidence of any hip disease directly related to service. Therefore, the Board finds that the surgeon’s opinion is not persuasive as it does not contain medical reasoning of why the Veteran’s avascular necrosis of left hip with segmental collapse is secondary to his right hip replacement. The recitation that the Veteran had avascular necrosis in service is an incorrect factual premise, which lessens the credibility of the opinion. In a February 2007 VA examination, a doctor who was a Diplomate of the American Board of Orthopedic Surgery, noted that “based on this patient’s history, review of his C-file, and examination to date, this patient’s right total hip arthroplasty, osteonecrosis of his left hip with segmental collages…. are not caused by or a result of trauma while in service… The patient developed bilateral avascular necrosis of his hips which is loss of vascular supply, 85 percent of the time this is idiopathic meaning that there is no underlying cause. A small percentage of the time it is due to administration of Prednisone or significant trauma such as hip dislocation that would usually be unilateral and not bilateral.” The examiner indicated disagreement with prior evaluators that the Veterans ’s right hip arthroplasty should be adjunct to his right knee also, as that is a vascular developmental condition of his hips that is a “stand alone entity.” The examiner noted that there was nothing in the current orthopedic literature that documented altered gait mechanics as a source or cause of osteonecrosis of the hips. In August 2007, during a VA examination, a physician reviewed with the Veteran the “impression that [the Veteran’s] claimed… osteoarthritis in his left hip is more likely related to overweight status and aging than to remote past pathology in right hip.” On VA examination in January 2012, the examiner found that the Veteran’s left hip status post total left hip replacement was less likely as not due to or a result of the right hip disability. The examiner based that opinion on medical literature review, medical record review, and clinical experience. The examiner provided the rationale that the service medical records were silent for any type of left hip condition during service or within close proximity to release from service. Intercurrent injury was unknown. There was no evidence in the medical literature to support a causal connection between a right hip replacement and the development of degenerative joint disease in the contralateral hip. The Board finds the January 2012 examiner’s conclusion to be highly probative, as it is based on a sound rationale. The examiners conclusion is based on a full review of the Veteran’s medical records, medical literature and clinical experience. The examiner notes, “that the Veteran’s service treatment records are silent for any type of left hip condition during service or within close proximity to release from service and that there is no evidence in the medical literature to support a causal connection between a right hip replacement and the development of degenerative joint disease in the contralateral hip.” Particularly, this examination states that the “Veteran’s left hip degenerative disease s/p total left hip condition is less likely as not due to or a result of the right hip condition.” Therefore, the Board finds that comprehensive examination report to be of high probative weight and dispositive of the claim. The evidence does not show that arthritis developed within one year of separation from service or any continuity of symptomatology of arthritis of the left hip since service. Therefore, service connection based on continuity of symptomatology or presumption of service connection must be denied. The Board acknowledges that VA is statutorily required to resolve reasonable doubt in favor of the Veteran when there is an approximate balance of positive and negative evidence regarding the merits of an outstanding issue. The Board is appreciative of the Veteran’s faithful and honorable service to our country. It is clear from the record that the Veteran has a lengthy history of hip problems. However, because the preponderance of the evidence is against the claim for service connection for left hip disability, the claim must be denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Harvey P. Roberts Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD E. Mondesir, Law Clerk