Citation Nr: 18151350 Decision Date: 11/20/18 Archive Date: 11/16/18 DOCKET NO. 14-40 276A DATE: November 20, 2018 ORDER Entitlement to service connection for a right hip condition is denied. FINDINGS OF FACT 1. The Veteran’s right hip condition is congenital in nature and therefore clearly and unmistakably existed prior entry onto active service. 2. The evidence of record is against finding that the Veteran has a right hip condition was worsened during her active service. CONCLUSION OF LAW The criteria for entitlement to service connection for a right hip condition are not been met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.306(a). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from August 1988 to June 1990. The Veteran testified at a March 2018 Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. In June 2012, the Veteran filed a claim for service connection, asserting that she developed a hip disability as a result of her military service. Specifically, the Veteran has been diagnosed with congenital hip dysplasia, and she believes that her participation in high impact training while in service caused deterioration in the hip that subsequently led to cysts, tears, osteoarthritis, and ultimately required a right hip replacement. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131. A Veteran is presumed to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted on the entrance examination report. 38 U.S.C. § 1132; 38 C.F.R. § 3.304(b). The presumption of soundness is rebutted where clear and unmistakable evidence demonstrates both that an injury or disease existed prior to service and was not aggravated by such service. 38 C.F.R. § 3.304(b). In determining whether there is clear and unmistakable evidence that an injury or disease existed prior to service, the Board must consider the history recorded at the time of examination together with all other material evidence, including medical judgments, accepted medical principles, and the veteran’s history of clinical factors. Harris v. West, 203 F.3d 1347 (Fed. Cir. 2000). The Veteran’s service medical records are silent for report problems with her hip. The Veteran’s entrance and separation examinations are also silent for any notation of a hip condition. It is noted that the Veteran has reported experiencing hip problems during service, but was avoided going to sick call for fear of reprimand. However, a review of the service treatment records suggests that the Veteran frequently visited the medical facilities while in service, including for a series of orthopedic problems. During an October 2009 treatment encounter, the Veteran reported intermittent episodes of mild right hip pain since her teenage years. She reported that such pain was typically aggravated by running and high impact exercises, but she asserted that the symptoms had always been minimal until May 2009 when she tripped over something in the backyard and landed on the lateral aspect of her right hip. The fall was described as a “very forceful impact, such that she was unable to stand for about 20 minutes.” She experienced “very significant pain” for several days and thereafter experienced fairly constant pain in the groin that radiated to the thigh and some painful catching. The pain was noted to be aggravated by stairs, weightbearing activities, and prolonged driving, causing the Veteran to stop exercising. Prior to the fall the Veteran exercised about two hours daily. An August 2009 MRI was reviewed and noted to be poor quality; an MRI arthrogram was ordered. During a November 2009 treatment encounter, the Veteran reported discomfort in her hip since high school. She reported military service as a paratrooper and the ability to “perform all activities, but had discomfort.” She experienced increasing discomfort over the past two years causing her to take Motrin regularly, and began experiencing pain on a regular basis since falling approximately five to six months prior. She was noted to have current difficulty for driving, standing, walking, and running with pain that wakes her from sleep at night. The physician noted an October MRI arthrogram that showed articular cartilage remained relatively preserved throughout the joint, anterior subchondral cyst associated with paralabral detachment. The Veteran was assessed with acetabular dysplasia with labral tear and subchondral cyst. The physician’s treatment plan noted that the Veteran’s symptoms were secondary to instability and recommended stabilization using periacetabular osteotomy. The physician also noted risk for waiting six months for treatment “because of the progressive deterioration.” A November 2012 MRI indicates that the Veteran experiences congenital hip dysplasia. The MRI impression noted mild osteoarthritis of the right hip with extensive cartilage loss and subchondral cystic changes in the acetabulum. During a November 2012 treatment visit the Veteran reported that symptoms of right hip pain with radiation into the thigh began spontaneously one year ago and steadily increased since. It was noted that the Veteran had no specific history of trauma, but has been “very aggressive with her physical activities her whole life.” The Veteran was diagnosed with degenerative joint disease of the right hip with acetabular dysplasia. A January 2014 private disability benefits questionnaire indicates the Veteran was diagnosed with osteoarthritis of the right hip, labral tear of the right hip, and right hip dysplasia. The Veteran reported mild right hip pain as a teen, that intensified when performing active duty activities such as running and jumping. The Veteran also reported that her right hip pain intensified in May 2009 when she tripped and fell onto her right hip. The Veteran was noted to have a total right hip replacement in 2012. A January 2015 private medical opinion states that due to the Veteran’s in-service physical activities, “I could see that there could be a possibility that this aggravated her chronic hip condition and made it worse. I can see that her condition would have progressed quicker than it would had she not done this physical activity.” However, “could be” in the context of a medical opinion is the same as “could not be” and therefore cannot provide the requisite nexus. See Obert v. Brown, 5 Vet. App. 30, 33 (1993). A November 2015 treatment record indicates that the Veteran fell in June 2015 and sustained a nondisplaced medical acetabular fracture. An undated private opinion, received July 2017, states that research supports that high impact activity, especially repetitive force causes degeneration of the joint, adding that “[i]t is not unreasonable to believe that those activities and repetitive forces played a role in advanced aging of the joint leading to her total hip replacement.” Given the suggestion that the Veteran’s hip problem might have been aggravated by service, the Board obtained an expert medical opinion. In May 2018, a Board-certified orthopedic surgeon reviewed the Veteran’s claims file and opined that the Veteran’s hip dysplasia clearly and unmistakably existed prior to active service as the condition is congenital and does not improve, but does deteriorate. The clinician also stated that the Veteran’s hip dysplasia was clearly and unmistakably not aggravated by active service as the service medical records were silent for complaints of hip pain during active duty. The clinician opined that the Veteran’s hip dysplasia was less likely than not to have been caused by her military service. The clinician noted that an MRI conducted approximately 17 years after the Veteran’s separation from service showed mild osteoarthritis. Additionally, the clinician noted that one would expect development of a more fulminant arthritis closer to her ative duty service if the condition was aggravated by service. Further, the clinician noted that the natural history of hip dysplasia is one of progression in most cases to osteoarthritis, and that the subchondral cyst formation and labral tears represent sequelae of the osteoarthritis which follows hip dysplasia. A September 2018 private medical opinion states that the Veteran’s military trainings would have aggravated her hip dysplasia. The physician goes on to state that the Veteran’s need for a total hip replacement at the age of 42 would have been secondary to being born with congenital hip dysplasia and her overuse of her hip during her time in the military. The physician notes providing pain management treatment for the Veteran since October 2016 and the Veteran’s reported history of congenital hip dysplasia, total hip replacement, and “typical military training” and military police training. An October 2018 private medical opinion states the Veteran’s extensive physical training during active service more likely than not aggravated her congenital hip dysplasia. The physician stated that the Veteran’s extensive tearing of the acetabular labrum and arthritis “seems like it would be more than what I would expect for the hip dysplasia she had.” In December 2016, the Veteran submitted a portion of the Borden Institute Study entitled, “Musculoskeletal Injuries in Military Women.” The study forward indicates that a comprehensive monograph was conducted which addresses the incidences, risk factors, prevention, diagnosis, evaluation, treatment and rehabilitation of common musculoskeletal overuse and traumatic injuries sustained by women in the military. The study highlights the difference between women and men in the rate and distribution of musculoskeletal overuse and traumatic injuries. The authors assert that the combination of anatomy and physiology appears to predispose women to higher risk of musculoskeletal overuse and traumatic injuries. The article identifies common injuries women have a higher incidence of experiencing, discusses risk factors of such injuries, and suggest methods to identify the injuries. The article indicates a higher incidence of overuse stress fractures for women in the military and notes several possible anatomical and physiological risk factors, to include the endocrine system, race, and levels of aerobic fitness. The article also notes that while previous studies indicate that men experience higher incidents of traumatic injuries than women, women experience some common traumatic injuries at higher rates, to include acetabular labral tears. The Veteran submitted a buddy statement from a soldier who served with her indicating that the Veteran “battled with intense pain” and “complained regularly about hip and pelvic pain” while the two served together. This statement noted that the Veteran was often seen performing “over-intensive physical training,” including carrying an M-60 for extensive road marches and required “physical training after duty hours.” The statement also asserts that the Veteran was punished or retaliated against by superiors for complaining about sexual harassment in the unit. Thus, at times the Veteran avoided sick-call for severe pain for fear of retaliation be her non-commissioned officer in charge (NCOIC). In a notice of disagreement received December 2013, the Veteran stated that during her active service she ran a minimum of five miles daily with a full pack and M-16. She also stated she did not seek treatment for the constant pain because she was the subject of harassment and did not want to draw more harassment and attention to herself. Instead, she used over the counter (OTC) medications and a hot pad to alleviate the pain. She reported continuing pain and using the same treatment after her separation from service. The Veteran stated she sought medical treatment when she could no longer take the pain. In December 2016, the Veteran submitted written correspondence in support of her claim. The Veteran stated that her severe right hip pain began during her military service while in basic training and has progressed over the years until 2009 when she was diagnosed with hip dysplasia. The Veteran stated that she was told by her physician that she had the “hip joint of a 90-year-old” and required a total hip replacement. During active service, the Veteran indicates that she attributed her hip pain to training and fatigue as her peers were experiencing similar aches and pain. The Veteran described her training as including two to five miles runs, carrying heavy equipment (weapon, ruck sack), and crossing rough terrain for lengthy periods of time. When participating in this training, the Veteran would often experience intermittent sharp and aching pains in the groin and hip. However, she did not report to sick call or complain of the pain because it was discouraged/frowned upon. The Veteran testified at a Board hearing that she began feeling hip pain in the military. Specifically, she reported experiencing pain while training, recalling that the pain arose depending on the activity performed during the day, and by mid- afternoon she would have to take Motrin for pain. The Veteran stated that she thought the pain was because her body was not familiar with such intense training, but the pain continued and “stayed about the same the entire time.” After a careful review of the evidence of record, the Board finds that entitlement to service connection for right hip dysplasia is not warranted. While the Veteran has a clear diagnosis of congenital right hip dysplasia, the evidence is against a finding that this disease, which is congenital in nature, was aggravated during her military service. As noted, there is no record of any hip complaints in the service treatment records. The evidence of record and the nature of the disease leaves little doubt that the Veteran’s hip dysplasia would have existed at the time that she entered active duty and in fact has been present since the Veteran’s birth. The evidence also clearly demonstrates that this disease was not permanently aggravated during her active service, especially in light of the lack of in-service symptoms; the condition’s slow progress, as was demonstrated by the lack of a diagnosis until 2009; and her ability to engage in intense physical activity for several years after separation from service, including daily workouts lasting approximately two hours. While the Veteran concludes that her congenital hip disability was aggravated by her active service the Board finds her conclusion offers little probative value and affords it little weight. Madden v. Brown, 125 F.3d 1477, 1481 (Fed. Cir. 1997). While the Veteran is certainly competent to testify as to her complaints related to her right hip condition, and there is evidence that she is a registered nurse, the Veteran’s conclusion is unsupported by her own statements and the objective medical evidence. Madden, 125 F.3d at 1481. The record contains no objective evidence of in-service complaints or treatment for hip problems. The Board notes the Veteran’s assertion that she did not seek treatment for her hip because it was frowned upon and did not want to draw additional harassment from her superiors. Significantly, the record indicates that the Veteran sought medical treatment regularly during her active service to include treatment for complaints of pain in her feet and back, however, there is no complaint or treatment for hip pain. Further, the Board notes that the Veteran’s report of symptomatology is conflicting. In written correspondence and testimony, the Veteran has asserted significant in-service pain, clicking sounds, and the need to take OTC medications daily to address the exacerbation of her symptoms. Further she has asserted that the symptoms of significant pain and the need for OTC medications continued after her separation from service, until she could no longer take the pain and sought additional treatment options. Contrasted with contemporaneous report of symptoms in 2009, when the Veteran described her symptoms since her teenage years as intermittent and mild. At that time, she described her in-service symptoms as discomfort and also reported that symptoms have always been minimal until approximately 2007 when she began experiencing increasing discomfort, followed by a May 2009 fall when she began experiencing regular pain. 2009 treatment records also indicate that it was the Veteran’s constant pain and aggravating factors of stairs, weightbearing activities, and prolonged driving subsequent to the May 2009 fall that caused her to seek medical treatment. Also notable, the post-service medical evidence indicates the Veteran’s condition began deteriorating in 2009. During her November 2009 treatment visit, the Veteran was noted to have relatively preserved articular cartilage, her symptoms were assessed as secondary to instability, and was warned against delaying treatment because of the progressive nature of her condition. By November 2012, the Veteran was noted to have extensive cartilage loss and required a hip replacement. Significantly, the remainder of the evidence of record (medical opinions, medical research, and buddy statements) does not establish aggravation of the Veteran’s congenital hip disability during her active service. Four private medical opinions are of record, but are insufficiently probative for the Board to make a determination. The January 2015, September 2018, and the undated opinions lack rationales for their conclusion. The October 2018 medical opinion indicates consideration of the Veteran’s current medical condition and report of military activity rather than full consideration of her medical history. Notably, there is no discussion of the significantly delayed onset of symptoms and deterioration of the condition, or the Veteran’s physically aggressive lifestyle (as reported by the Veteran) after her separation from service. The August 2018 VHA opinion provides more probative value than the private opinions as it includes full consideration of the Veteran’s medical history and includes rationale for its conclusions. The medical research submitted addresses the increased occurrence of certain musculoskeletal injuries in woman military personnel, but provides no support for the assertion that the Veteran’s disability was aggravated by her military service. Notably, the research indicates that not only military training, but additional risk factors exist for women military personnel that could explain the increased incidence of injury. The buddy statement submitted supports the Veteran’s assertion that she experienced in-service hip pain and participated in “over-intensive physical training,” but does not establish aggravation of the Veteran’s congenital hip dysplasia. The statement includes no indication that the Veteran was unable to perform her duties or experienced an objective change in the ability to perform required duties as a result of worsening of the Veteran’s hip dysplasia. Notably, in written correspondence, the Veteran stated that during active service she experienced similar aches and pain as her peers, rather than something outside the norm which would signal worsening of her hip condition. While it is not unreasonable to believe that high impact activity, repetitive force can cause degeneration of the hip joint, the preponderance of evidence does not indicate that such degeneration occurred during the Veteran’s active service. When taken together, the lack of in-service symptoms, the delayed onset of significant symptoms and the lack of a diagnosis until approximately two decades after separation from service, intensive physical activity for several years after separation from service, and the deterioration of the Veteran’s hip condition between 2009 and 2012, do not support a grant of service connection. MATTHEW W. BLACKWELDER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R. I. Sims, Associate Counsel