Citation Nr: 20003102 Decision Date: 01/14/20 Archive Date: 01/14/20 DOCKET NO. 12-32 692 DATE: January 14, 2020 ORDER Entitlement to service connection for a left hip disability, to include as secondary to a service-connected knee or back disability, is denied. FINDING OF FACT The preponderance of the evidence weighs against finding that the Veteran’s left hip disability is secondary to a service-connected knee or back disability or is otherwise related to an in-service injury or disease. CONCLUSION OF LAW The criteria for entitlement to service connection for a left hip disability, to include as secondary to a service-connected knee or back disability, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the U.S. Air Force from January 1957 to May 1976. Entitlement to service connection for a left hip disability, to include as secondary to a service-connected knee or back disability, is denied. The Veteran seeks entitlement to service connection for a left hip disability, which he avers is secondary to his service-connected knee or back disabilities. Generally, to establish a right to compensation for a present disability, a Veteran must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called “nexus” requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). All elements must be established by competent and credible evidence in order that service connection may be granted. Service connection may be established on a secondary basis for a disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Establishing service connection on a secondary basis requires (1) competent evidence (a medical diagnosis) of current chronic disability; (2) evidence of a service-connected disability; and (3) competent evidence that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310 (a); see also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Where the evidence shows a “chronic disease” in service or “continuity of symptoms” after service, the disease shall be presumed to have been incurred in service. 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. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. 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. 38 C.F.R. § 3.303 (b). Additionally, where a veteran served ninety days or more of active service, and certain chronic diseases, such as degenerative joint disease (arthritis), become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. 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). Turning to the evidence of record, the Board notes that the Veteran’s service treatment records reflect treatment for his bilateral knees, low back, quadriceps, and right hip, but are silent for complaint, treatment, or diagnosis of a left hip disability. In fact, in a July 1968 service treatment record regarding right hip pain, an examiner observed that both hips were radiographically normal. Within a year of separation from service, in July 1976, the Veteran was provided a VA examination. Radiographic testing done at that time revealed no evidence of significant hip abnormality. In June 1981, the Veteran underwent another VA examination. There, the examiner observed the movement of his hips was normal. Radiographic testing performed in December 2007 reflected marked degenerative changes in the Veteran’s left hip. In early October 2008, the Veteran underwent a left total hip arthroplasty. In June 2009, the Veteran attended a VA examination. The examiner first endorsed a review of the Veteran’s claims file. There, the Veteran stated that the pain in his left hip had begun two to three years prior. The Veteran was diagnosed with left hip degenerative joint disease, status post arthroscopy. The examiner concluded that there was no evidence on examination without resorting to mere speculation that the Veteran’s hip replacement and degenerative arthritis of the left hip were related to his service-connected left knee. While the Veteran did walk with a mild limp, the examiner noted that the limp was not of such a nature that he would expect arthritis to be aggravated or initiated at his left hip due to his left knee. Therefore, the examiner wrote, the arthritis and replacement of the left hip joint was not caused by the left knee, nor was it permanently aggravated by the left knee. He attributed the Veteran’s left hip condition to the natural progression of the degenerative disability. The Veteran was provided another VA examination in June 2010. The examiner first endorsed a review of the Veteran’s claims file. There, the Veteran reported that his left hip had begun to bother him in the late 1990s or early 2000s. The examiner determined that the Veteran’s degenerative arthritis of the left hip could not be attributed to anything that occurred during his military service. Specifically, the examiner found that it was less likely than not that the left hip degenerative arthritis and subsequent arthroscopy were related to his service-connected knee. The Veteran underwent another VA examination in October 2017. The examiner endorsed a review of the Veteran’s claims file. There, the Veteran stated that his left hip condition had not improved since his previous VA examination. The examiner opined that the Veteran’s left hip disability was not at least as likely as not proximately due to or the result of complaints of hip pain with quadricep atrophy and pelvic tilt shown in service. She noted the Veteran’s antalgic gait was a residual following his October 2008 left hip replacement. She further opined that the Veteran’s left hip disability was not at least as likely as not proximately due to or the result of the postoperative residuals, laminectomy and interbody fusion at the L4-5 level (back disability). The examiner noted that the Veteran underwent a lumbar laminectomy in 1969 and spinal fusion in 1987. She also observed that the Veteran had an antalgic gait. She determined that the abnormal gait was a residual following his October 2008 left hip replacement. Thus, she concluded that the Veteran’s left hip was less likely than not proximately due to or the result of postoperative residuals, laminectomy and interbody fusion at the L4-5 level (back disability). Later that month, the examiner provided an addendum opinion. She was asked to determine whether the hip disability that led to the Veteran’s hip replacement was at least as likely as not related to complaints made in service. The examiner noted that the Veteran complained of right hip and back pain in 1968. He was also shown to have completely recovered from a 1969 L4-5 laminectomy during his service. The examiner observed that the Veteran was not noted to have had a left hip condition during his military service. He was diagnosed with osteoarthritis after service, resulting in his 2008 hip replacement. She concluded that it was not possible to establish a causal nexus between the Veteran’s left hip disability that led to his left hip replacement and complaints in service without resorting to mere speculation. The undersigned Veterans Law Judge requested an independent medical opinion from an orthopedic surgeon which was received in May 2018. The independent medical examiner was asked whether it was at least as likely as not that the Veteran’s current degenerative joint disease of the left hip began in or was otherwise related to his service. Following a review of the claims file, he proffered his opinion. He determined that there was no evidence in the Veteran’s medical records that a left hip degenerative joint disease began in service. He found that there were no musculoskeletal issues related to the Veteran’s left hip in service. The independent medical examiner was also asked whether it was at least as likely as not that the Veteran’s current degenerative joint disease of the left hip was caused by or aggravated by service-connected left and/or right knee disabilities. He observed that there has never been a published study linking the causality (emphasis found in the medical opinion) of osteoarthritis to another degenerative joint. He noted that there were some biomechanical studies which suggested that osteoarthritis may progress to other joints if one joint was affected; however, he stated that he could not say that there was a 50 percent or greater probability of such. The examiner also discussed a paper written in 2011 which gave the rates of progression to total joint arthroscopy after a total knee was performed. However, as the examiner himself was the primary author, he indicated that the paper only addressed the degree of arthritis in the primary osteoarthritic knee joint. The study did not look at the degree of osteoarthritis in other joints when predicting the percentage chance that a joint replacement would be performed in another joint. He observed that there were no other studies that he was aware of that looked at the degree of osteoarthritis in the hips after a knee replacement is performed which was predictive of hip replacement surgery. The examiner further noted that aggravation of the Veteran’s left hip by his either or both knees was not shown in the record. Finally, the independent medical examiner was asked whether it was at least as likely as not that the Veteran’s current degenerative joint disease of the left hip was caused or aggravated by service-connected back disability. He referred to his previous answer, stating that there were no studies relating the progression of osteoarthritis of the hips to surgery of the lower back. He also noted that there was not a 50 percent or greater probability that the hip arthritis was aggravated by the Veteran’s back symptoms. After considering all the evidence of record, with specific attention to the documents discussed above, the Board finds that there is no basis for direct service connection for a left hip disability. Notably, the Veteran himself has not averred that the claimed disability was incurred in service. Additionally, there is no objective evidence that a left hip disability was incurred in or began during his active duty military service. The Veteran’s service treatment records, while rife with instances of treatment for other disabilities, are noticeably silent regarding any event, injury, or disease to his left hip. Thus, service connection on a direct basis is not warranted. Further, as the Veteran’s service treatment records do not reveal symptoms of or a diagnosis of a chronic left hip disability during service, and the Veteran’s initial complaints of left hip pain and diagnosis of degenerative joint disease was not until the early to mid-2000s, decades after service, the Veteran may not be presumptively service-connected based on continuity of symptomatology or based on the manifestation of a chronic disease to a compensable degree within one year of separation. The Board now turns to the Veteran’s main contention, that his left hip disability is related to his service-connected knee or back disabilities. The Veteran has expressed his sincere belief that his left hip disability is proximately due to or the result of or aggravated beyond its natural progression by a service-connected disability, to include his knee and back disabilities. However, the Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of orthopedic anatomical relationships and the interpretation of diagnostic medical testing. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the skills or medical training to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Thus, the Board must look to the medical evidence of record to determine whether an etiological relationship exists been his claimed disability and his service-connected disabilities. Several medical opinions have been rendered regarding the proposed relationship between the Veteran’s left hip disability and his service-connected disabilities. The Board notes that both the June 2009 and second October 2017 medical opinion were speculative and, as such, are of low probative value. See Bostain v. West, 11 Vet. App. 124, 127-28, quoting Obert v. Brown, 5 Vet. App. 30, 33 (1993) (a medical opinion expressed in terms of “may” also implies “may or may not” and is too speculative to establish a causal relationship. Further, the Board notes that the June 2010 medical opinion contained no rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (stating that “[i]t is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes probative value to a medical opinion”). Additionally, the first October 2017 medical opinion was predicated on an inaccurate factual premise, that the Veteran had complained of left hip pain during service, and merely restated portions of the facts (the presence of the Veteran’s antalgic gait post-total hip arthroplasty) with no reasoning. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (A medical opinion is only as good and credible as the history on which it was based, and if based on an inaccurate factual premise it has no probative value). Thus, these opinions are also of low probative value. Of the greatest probative value in this case is the May 2018 independent medical opinion. This opinion was proffered by an orthopedic surgeon who relied on a thorough review of the claims file, as well as his demonstrated knowledge, training, and expertise when giving his opinion. The examiner found no etiological relationship between the Veteran’s left hip disability and his service-connected knee or back disabilities, nor did he find that the Veteran’s service-connected disabilities aggravated his left hip disability. In so finding, the Board notes that the Veteran has not provided an alternative medical opinion nor has he supported his contentions with examination reports or findings that relate his left hip disability to his service-connected knee or back disabilities. Compared to the probative independent medical opinion, the Veteran’s bare assertions of an etiological relationship are of little or no probative value. The preponderance of the evidence being against this claim, the benefit of the doubt standard of proof does not apply, and the claim must be denied. 38 U.S.C. § 5107 (b). JENNIFER HWA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board L. Bush The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.