Citation Nr: 1814964 Decision Date: 03/13/18 Archive Date: 03/19/18 DOCKET NO. 00-11 579 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for avascular necrosis of the right hip, status post total hip replacement, to include as secondary to service-connected bilateral knee and ankle disabilities. 2. Entitlement to service connection for avascular necrosis and degenerative joint disease of the left hip, status post total hip replacement, to include as secondary to service-connected bilateral knee and ankle disabilities. (The issue of entitlement to automobile and adaptive equipment is addressed in a separate decision.) REPRESENTATION Veteran represented by: Mr. Daniel G. Krasnegor, Attorney at Law ATTORNEY FOR THE BOARD J. Murray, Counsel INTRODUCTION The Veteran had active service in the United States Army from June 1976 to January 1977. These matters come before the Board of Veterans' Appeals (Board) on appeal from a December 2005 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas, which, in pertinent part, denied service connection for a hip disability. In a March 2008 decision, the Board denied service connection for a hip disability. Thereafter, the Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (Court). In a January 2010 memorandum decision, the Court vacated the March 2008 decision and remanded the case to the Board. In August 2010, December 2012, May 2015, and July 2016 the Board remanded the issues for further development. FINDINGS OF FACT 1. The competent evidence does not demonstrate that the Veteran's current avascular necrosis of the right hip manifested during service or within a year following separation from service. 2. The preponderance of the competent evidence is against a finding that the Veteran's current right hip disorder is etiologically related to service, to include as proximately caused or aggravated by his service-connected knee, ankle, and lumbar spine disabilities. 3. The competent evidence does not demonstrate that the Veteran's avascular necrosis with degenerative arthritis of the left hip manifested during service or within a year following separation from service. 4. The preponderance of the competent evidence is against a finding that the Veteran's current left hip disorder is etiologically related to service, to include as proximately caused or aggravated by his service-connected knee, ankle, and lumbar spine disabilities. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a right hip disorder, to include as secondary to service-connected disabilities, have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2017). 2. The criteria for entitlement to service connection for a left hip disorder, to include as secondary to service-connected disabilities, have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS 1. VA's Duty to Notify and Assist VA satisfied its duty to notify the Veteran pursuant to the Veterans Claims Assistance Act of 2000 (VCAA) in a December 2004, a February 2006, and a March 2006 letters. 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), 4.2 (2017). Concerning the duty to assist, the record reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran, including his service treatment records, post-service treatment records, and VA medical opinion and examination reports. The record also contains various statements submitted by the Veteran and his representative in support of his claims. The Board finds that there has been substantial compliance with the prior 2010, 2012, 2015, and 2016 remand instructions, and no additional actions are needed at this time. See D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998)). The Veteran was afforded a VA hip examination in September 2016, and VA medical opinions were obtained in September 2016 and May 2017 regarding the etiology of the Veteran's claimed right and left hip disorders. The Board has considered the Veteran's representative's assertions regarding the adequacy of these VA medical opinion. In a January 2018 informal hearing presentation, the Veteran's representative contends that the September 2016 VA medical opinion and May 2017 addendum medical opinion were inadequate because the examiner failed to address lay evidence of in-service injury and chronicity of symptoms. Both the U.S. Court of Appeals for Veterans Claims (Court) and the Federal Circuit have held, however, that the Board is entitled to presume the competence of a VA examiner and specific challenges to a VA examiner's competency must be raised by the appellant to overcome this presumption. See Rizzo v. Shinseki, 580 F.3d 1288 (Fed. Cir. 2009) and Bastien v. Shinseki, 599 F.3d 1301 (Fed. Cir. 2010); see also Cox v. Nicholson, 20 Vet. App. 563, 569 (2007) (citing Hilkert v. West, 12 Vet. App. 145, 151 (1999)). The Court held in Cox that "the Board is entitled to assume the competence of a VA examiner." Id. at 569. Absent evidence or argument which called in to question a VA examiner's professional competence, the Court concluded in Cox that it is not error for the Board to presume that a VA examiner is competent. Id.; see also Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (explicitly extending the presumption of competence discussed in Cox and Rizzo to VA examiners). Neither the Veteran nor his service representative has raised a specific challenge to the professional medical competence or qualifications of the VA examiners who provided the September 2016 VA examination report and May 2017 addendum opinion. The Board finds that the examiners are competent and will assign appropriate probative weight to the opinions. As explained in greater detail below, the Board finds that VA's duty to assist with respect to obtaining an adequate VA examination has been met as to the issues being decided. 38 C.F.R. § 3.159 (c)(4). The Veteran has not raised any other issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). 2. Service Connection 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 (2012); 38 C.F.R. § 3.303 (2017). Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Certain chronic diseases, to include arthritis, although not shown in service, may be presumed to have incurred in or aggravated by service if they become manifested to a compensable degree within one year of separation from active duty. 38 U.S.C. §§ 1101, 1112, 1113 (2012); 38 C.F.R. §§ 3.307, 3.309 (2017). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. See 38 C.F.R. § 3.303 (b). The chronicity provision of 38 U.S.C. § 3 .303 (b) is applicable where the evidence, regardless of its date, shows that the Veteran had a chronic condition in service or during an applicable presumption period and still has such condition. Regulations also provide that service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury which was incurred in or aggravated by service. 38 C.F.R. § 3.303 (d). To prevail on the issue of service connection, 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) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In addition, a disability that is proximately due to or the result of a service-connected injury or disease shall be service connected. 38 C.F.R. § 3.310 (2017). When service connection is thus established for a secondary condition, the secondary condition shall be considered part of the original condition. 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) caused by or (b) aggravated by a service-connected disability. Id. The determination as to whether the requirements for service connection are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. 38 U.S.C. § 7104 (a) (2012); Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303 (a). If there is at least an approximate balance of positive and negative evidence regarding any issue material to the claim, the claimant shall be given the benefit of the doubt in resolving each such issue. 38 U.S.C. § 5107 (2012); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); 38 C.F.R. §§ 3.102 (2017). On the other hand, if the Board determines that the preponderance of the evidence is against the claim, it has necessarily found that the evidence is not in approximate balance, and the benefit of the doubt rule is not applicable. Ortiz, 274 F.3d at 1365. In this case, the Veteran seeks entitlement to service connection for right and left hip disorders. He asserts that his current left and right hip disorders are a result of injuries he incurred during his period of service. In the alternative, he believes that his current hip disorders are secondary to his service-connected knee, ankle, and lumbar spine disabilities. The Veteran contends that he developed his current bilateral hip problems as result of an abnormal gait attributed to his service-connected disabilities. The medical evidence of record establishes that the Veteran has current disabilities involving his hips, identified as avascular necrosis in both hips and degenerative arthritis in the left. He has undergone total hip replacement on both hips. See VA and private treatment records as well as the September 2016 VA examination report. A review of the Veteran's service treatment records do not show treatment or complaints for any hip problems, and a medical examination report prior to separation is not available. The service treatment records do show that the Veteran received in-service treatment for knee, ankle, and lumbar spine problems, and a December 1976 service treatment record noted that the Veteran had a slight antalgic gait due to left knee pain. In support of his claims, the Veteran has submitted copies of four handwritten letters that he wrote to his family during his period of service. Two of the letters are dated (November 1979 and January 1977) and two letters are not dated. In these letters, the Veteran complained of pain and discomfort in his legs and he described his legs as "banged up" from participating in training activities that involved running, dodging, and jumping. In the January 1977 handwritten letter, the Veteran reported that "my leg was all messed up" after participating in a long training march. In these letters, the Veteran specifically mentions injury to his right ankle and left knee, but he does not identify specific injury to his right or left hip. Rather, in the letters, the Veteran reports injury and ongoing problems with his legs in general during his military service. The Veteran has also submitted statements from family and friends who describe that the Veteran had bilateral hip problems as result of injuries in service and aggravated by an altered gait due to his service-connected knee and ankle disabilities. See March 2006 and May 2008 statements in support of the case from family and friends. The first post-service medical evidence of hip problems comes in February 1998 following injuries sustained from a motor vehicle accident (MVA). Private x-ray film of the pelvis revealed no hip bone abnormalities and good bone density was noted throughout the pelvis region. One week following the MVA, the Veteran presented with complaints of right leg pain, but it was noted that the x-ray film of the pelvis was negative. A December 1998 VA treatment record shows that the Veteran presented with complaints of hip pain since the February 1998 MVA, which he felt was getting worse. On his December 1998 application for compensation, the Veteran requested compensation for disability to right hip from a car accident in February 1998. VA treatment records starting in 2002 begin to show complaints of bilateral hip pain. See July 2002 VA treatment record. In March 2004, the Veteran sought private orthopedic consultation for his hip problems. The private orthopedic consultation report shows that the Veteran complained of right hip pain for many years, going back since his period of service, and which he felt was aggravated by injuries sustained in a 1998 motor vehicle accident. A March 2004 private x-ray film of the pelvis showed no evidence of acute fracture or significant degenerative changes, but avascular necrosis was suspected. The report of an April 2004 private MRI of the pelvis confirmed findings of avascular necrosis in both hips, worse on the right. The Veteran underwent a right total hip replacement in August 2004. Later private treatment records show that the Veteran developed degenerative arthritis secondary to avascular necrosis in his left hip. See May 2010 private treatment record. He underwent a left total hip replacement in November 2010. Here, the medical evidence of record does not show that the Veteran's right and left hip disorders first manifested in service, at separation, or until more than a year after his discharge from active service. See 38 C.F.R. §§ 3.303, 3.307, 3.309. VA and private treatment records do not show that the Veteran's current right and left hip disorders had an onset during his period of service. The February 1998 private x-ray of the pelvis showed no abnormalities involving either hip, and the first competent evidence of current right and left hip disorders, avascular necrosis, is not shown until 2004, which comes decades after his separation from service. See 38 C.F.R. § 3.303; see also Maxson v. West, 12 Vet. App. 453 (1999), aff'd, 230 F.3d 1330 (Fed. Cir. 2000) (to the effect that service incurrence may be rebutted by the absence of medical treatment for the claimed condition for many years after service). Evidence of in-service disease involving the right and left hips has not been shown, and service connection is not warranted on a presumptive basis for chronic disease which manifest to a compensable degree within one year of the Veteran's separation from service. See 38 C.F.R. §§ 3.303, 3.307, and 3.309. With respect to in-service injury, the Veteran's service treatment records do not show a chronic problem involving his hips. However, the copies of the Veteran's handwritten letters from service provides competent lay evidence of injuries to his legs from participating in training activities during service and he has also provided lay statements of hip problems during his period of service. As such, in-service injury has been shown for each claimed disorder. With respect to evidence of a medical nexus or relationship, there is no favorable medical opinion of record that supports a direct relationship between the Veteran's current diagnosed right and left hip disorders and his injuries incurred during his period of service. Rather, the record contains a VA medical opinion that weighs heavily against the Veteran's claims. In a September 2016 VA examination report, the VA examiner concluded that based on a review of the claims folder, it was less likely than not that the Veteran's right and left hip disorders were directly related to his period of service. In support of this medical conclusion, the VA examiner noted that a review of the Veteran's service treatment records did not show complaints of, or treatment for, hip problems, and post-service treatment records do not show his current diagnosed hip disorders manifested within one year of his separation from service. In addition, the VA examiner noted that while the exact mechanism for the development of avascular necrosis is unknown, it is suspected that the interruption of blood supply (anoxia) to the affected hip bone plays a role. The VA examiner noted that there are multiple risk factors for the development of avascular necrosis in the hips. However, based on the review of the Veteran's medical history in his treatment records, it is more likely that he developed avascular necrosis in the hips due to alcoholism and tobacco abuse as there was no evidence of direct injury, fracture or dislocation of either hip. In a July 2017 addendum medical statement, the same VA examiner considered the Veteran's handwritten letters to his family during his period of service which contained complaints involving both lower extremities. The VA examiner specifically considered the Veteran's November 1976 remark that there was something wrong with his leg and his January 1977 statement in which he mentions that his leg was messed up from a long training march. The VA examiner also considered the Veteran statements about his legs and feet during his period of service, but the VA examiner found that the lack of clinical or objective medical evidence of hip problems in service and for decades afterwards to be more probative. The VA examiner concluded that it was less likely than not that the Veteran's current bilateral hip disorder is not related to his period of service, to include his claimed in-service injuries. There is no medical opinion to the contrary that supports a direct relationship to the Veteran's period of service. The Board has considered the Veteran's representative assertion that the VA opinion was inadequate because it relied on an absence of treatment. See January 2018 informal hearing presentation. To the contrary, however, the Board believes that the VA examiner specifically discussed the Veteran's reports of injury documented in his handwritten letters from service, as well as his complaints following service, but explained that the lack of clinical evidence of hip problems until decades after service did not support a relationship between the Veteran's current diagnosed hip disorders and his complaints in-service. The Board finds that, in the aggregate, the September 2016 VA medical opinion and July 2017 addendum medical opinion are adequate to decide the claim. The examiner noted the Veteran's lay statements, and medical history, along with his clinical observations. The examiner acknowledged the Veteran's lay statements of in-service leg problems, but reasoned that the Veteran's long history of alcoholism and tobacco abuse where most likely the cause of the avascular necrosis in his hips. Therefore, the Board finds that the opinions in aggregate are sufficient to decide the claim because the Veteran's lay statements were considered and the Veteran's entire medical history was taken into consideration. As noted above in the legal criteria above, under 38 C.F.R. § 3.303 (b), an alternative method of establishing the second and third service-connection element for certain chronic diseases, including arthritis, is through a demonstration of continuity of symptomatology. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Although the Veteran asserts that he has experienced symptoms of hip problems continuously since his period of service, the Board finds the lapse in time after discharge from service to the showing of the current disorders as well as the VA examiner's medical opinion to be highly probative evidence against the Veteran's claims. The Board has considered the Veteran's own statements which suggest that his current diagnosed disorders are associated with his period of service. While the Veteran is competent to describe his symptoms, as a layperson he and the Veteran are not competent to determine the cause of avascular necrosis. See Bostain v. West, 11 Vet. App. 124, 127 (1998). Here, however, the question of causation extends beyond an immediately observable cause-and-effect relationship and, as such, the Veteran is not competent to address etiology in the present case. See Sacks v. West, 11 Vet. App. 314, 316-17 (1998). This is especially true when the statements are compared to the comprehensive analysis provided by the VA examiners. Moreover, the Board doubts the credibility of the Veteran's reports of bilateral hip pains since his period of service. In this regard, the Veteran did complain of hip pain until after the February 1998 motor vehicle accidents. In several accounts to his treating physician as well as in his original claim for service in December 1998, the Veteran specifically reported onset of hip problems associated with the 1998 motor vehicle accident. The Board observes that the Veteran first reported that he suffered current hip problems more than two decades after his separation from service, and he did not report his hip problems until after an intervening post-service injury. It was not until well-after he submitted a claim for VA benefits that such assertions of continuity of symptoms were made. The Board finds this evidence recorded in conjunction with evaluation of the Veteran during service to have more probative value than his current recollections. See Curry v. Brown, 7 Vet. App. 59 (1994) (contemporaneous evidence can have greater probative value than inconsistent testimony provided by the claimant at a later date). Thus, after assessing evidence of record, the Board finds the Veteran's current assertions are not credible. The Veteran has not submitted competent or probative medical evidence that shows a positive association between his current right and left hip disorders and his active service. Based on the foregoing, the Board finds that element (3) a medical link between the Veteran's right and left hip disorders and his period of service has not been shown. As such, the Board finds that service connection on a direct basis is not warranted. Turning to the Veteran's alternative assertion - entitlement to service connection on a secondary basis, the remaining question is whether the medical evidence supports, or is at least in equipoise, as to the Veteran's assertion that his current bilateral hip disorder is proximately caused or aggravated by his service-connected knee, ankle, and spine disabilities. See 38 C.F.R. § 3.310. Here, the Board finds that the preponderance of the competent evidence of record weighs against a finding that the Veteran's current bilateral hip disorder is proximately caused or aggravated by his service-connected disabilities. The Veteran contends that he has an altered gait as result of his service-connected knee and ankle disabilities which has resulted in his current bilateral hip disorder. Here, a review of the evidence of record during service and since service does show that the Veteran had altered gait as result of his service-connected knee and/or ankle disabilities. In addition, in support of his claim, the Veteran has a March 2006 medical statement from his treating VA medical provider, in which she concluded that the Veteran has a hip disorder was at least as likely as not a related to altered gait and overcompensation for his service-connected knee and ankle disabilities. The treating VA medical provider stated that this medical opinion was support by a review of the medical records that showed the Veteran had longstanding leg and ankle problems in service and since then. In the September 2016 VA examination report, the VA examiner concluded that the Veteran's right and left hip disorders were not proximately caused or aggravated by his service-connected knee, ankle, and/or spine disabilities. This medical opinion was based on a review of the evidence, including after a review of the claims folder, including the findings from the private and VA medical records. In support of the medical opinion, the VA examiner stated that a review of the medical literature did not support a medical relationship between the Veteran's lumbar spine, knees, and right ankle disabilities and the anatomical and pathophysiologic condition responsible for avascular necrosis of the hips. The VA examiner further stated that the medical literature also did not demonstrate possible aggravation of avascular necrosis of the hip by the Veteran's service-connected lumbar spine, knees, and right ankle disabilities. The VA examiner noted that while the exact mechanism for the development of avascular necrosis is unknown, it is suspected that the interruption of blood supply (anoxia) to the affected hip bone plays a role. The VA examiner noted that there are multiple risk factors for the development of avascular necrosis in the hips. However, based on the review of the Veteran's medical history in his treatment records, it is more likely that he developed avascular necrosis in the hips due to alcoholism and tobacco abuse as there was no evidence of direct injury, fracture or dislocation of either hip. The 2016 VA examiner also specifically considered the previous medical opinions in the claims folder, and specifically disagreed the positive medical opinion from the Veteran's treating VA physician that a hip disorder was result of altered gait due to knee and ankle disabilities. The 2016 VA examiner specifically agreed with the previous VA medical opinions that concluded that the Veteran's hip disorders were not caused or aggravated by his service-connected bilateral knee and bilateral ankle disabilities. Again, the VA examiner found that based on review of the medical literature and the Veteran's medical history, it was more likely that the risk factors for his development of avascular necrosis of the hips were alcoholism and cigarette smoking. In this case, the Board finds that the 2016 VA examiner's medical opinion is more probative medical opinion of record weighs heavily against a finding that the Veteran's current bilateral hip disorder is secondary to his service-connected disabilities. An initial review of the treating VA physician's 2006 medical opinion appears to support the Veteran's claims, but a close analysis shows it has limited probative value. The medical opinion appears to be based upon an incomplete review of the record, and does not discuss the impact of the Veteran's long history of alcohol and tobacco abuse on the development of avascular necrosis in his hips. In contrast, the 2016 VA medical opinion is based on a thorough review of the Veteran's medical records, including the VA physician's medical statement, and supported by a rationale statement that discusses the nature of avascular necrosis and likely risk factors. The 2016 VA opinion is also based on an accurate understanding of the Veteran's medical history, specifically long history of alcohol and tobacco abuse, which was not discussed by the treating VA physician. As such, the Board assigns greater probative value to the 2016 VA medical opinion than the 2006 medical opinion from the Veteran's VA treating physician. The Board acknowledges that in the report of a July 2014 VA examination, the VA examiner stated that a bilateral hip condition, especially for the Veteran's left hip, is often associated with a lumbar spine condition. (The Veteran has since been service-connected for his lumbar spine disability.) However, the July 2014 VA examiner did not provide any further statement explaining how the Veteran's bilateral hip disorder was associated with his lumbar spine disability. Instead, the 2014 VA examiner noted that there is no anatomical connection between individual degenerative joint disease or inflammatory conditions of the joints, and that avascular necrosis is not related to arthritis. Avascular necrosis is defined as a loss of blood supply to the specific affected joint. Notably, the September 2016 VA examiner provided a similar rational statement that discusses how the Veteran's avascular necrosis in the right hip and avascular necrosis with degenerative arthritis in the left are not proximately caused or aggravated by the lumbar spine disability. Again, the 2016 VA examiner found that the Veteran's avascular necrosis of the hips were most likely the result of his history of alcoholism and tobacco use. Here, the Board finds that the 2016 VA medical opinion weigh heavily against the Veteran's claims, and outweighs the statement contained in the July 2014 VA medical opinion report that suggests an association to the lumbar spine disability. The Board has also considered the Veteran's assertions that his current right and left hip disorders are related to his period of service or as secondary to his service-connected disability. However, there is no indication in the record to suggest that the Veteran has specialized training so as to be able to provide an etiology between his current bilateral hip disorder and his periods of service or secondary to service connected disabilities through his observation of his symptomatology alone. See Barr v. Nicholson, 21 Vet. App. 30 (2007); see Rucker v. Brown, 10 Vet. App. 67, 74 (1997). Notably, the determination of the nature and etiology of avascular necrosis requires diagnostic testing and medical expertise to determine its very nature, which would extend beyond the Veteran's capabilities to assess his condition. Rather, the more probative competent medical opinion of record come from the VA examiners, and those opinions weigh heavily against the Veteran's claim. In sum, the weight of the evidence is against a finding that the Veteran's current right and left hip disorders are directly related to service. Furthermore, the Board finds that the VA examiner's medical opinion carries more weight against the claim on secondary basis. The preponderance of the medical evidence is against a finding that the Veteran's right and left hip disorders are etiologically related to the Veteran's period of service, to include as secondary to his service-connected disabilities. As such, the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). The claims must be denied. ORDER Entitlement to service connection for a right hip disorder, to include as secondary to service-connected disabilities, is denied. Entitlement to service connection for a left hip disorder, to include as secondary to service-connected disabilities, is denied. ____________________________________________ MICHAEL A. PAPPAS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs