Citation Nr: 20004864 Decision Date: 01/23/20 Archive Date: 01/21/20 DOCKET NO. 14-29 797 DATE: January 23, 2020 ORDER Entitlement to service connection for a left hip disability, to include as secondary to service-connected left knee and spine disabilities, is denied. Entitlement to service connection for a right hip disability, to include as secondary to service-connected left knee and spine disabilities, is denied. Entitlement to service connection for a right knee disability, to include as secondary to service-connected left knee and spine disabilities, is denied. FINDINGS OF FACT 1. The Veteran’s bilateral hip and right knee disabilities are not secondary to his service-connected left knee or spine disabilities and are not otherwise related to an in-service injury or disease. 2. The Veteran’s bilateral hip and right knee arthritis were not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not shown; and the disabilities are not otherwise etiologically related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The criteria for service connection for a right hip disability due to service or secondary to service-connected left knee and spine disabilities are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 2. The criteria for service connection for a left hip disability due to service or secondary to a service-connected left knee and spine disabilities are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 3. The criteria for service connection for a right knee disability due to service or secondary to a service-connected left knee and spine disabilities are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1974 to October 1978. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a February 2014 rating decision. The Veteran testified before the undersigned during a December 2017 hearing. This matter was previously before the Board in March 2018, when it was remanded for additional development. Service Connection Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110; 38 C.F.R. § 3.303. Establishing service connection generally requires evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). A disability may also be found service connected on a secondary basis by demonstrating that the disability is either (1) proximately due to or the result of an already service-connected disease or injury or (2) aggravated by an already service-connected disease or injury. See Allen v. Brown, 7 Vet. App. 439, 448 (1995); 38 C.F.R. § 3.310. Certain chronic diseases, including arthritis, may be presumed to have been incurred in or aggravated by service if they manifest to a compensable degree within one year of discharge from service, even though there is no evidence of such disease during service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309(a). Moreover, if those same diseases are noted during service, continuity of symptomatology can show chronicity and subsequent manifestations of the same disease is presumed to be service connected. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). A continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was “noted” during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage v. Gober, 10 Vet. App. 488, 495-99 (1997) (Overruled on other grounds by Walker, 708 F.3d 1331). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 1. Entitlement to service connection for a left hip disability, to include as secondary to service-connected left knee and spine disabilities 2. Entitlement to service connection for a right hip disability, to include as secondary to service-connected left knee and spine disabilities 3. Entitlement to service connection for a right knee disability, to include as secondary to a service-connected left knee disability The Veteran contends that his bilateral hip disabilities and right knee disabilities are the result of or aggravated by his service-connected left knee and spine disabilities, to include as a result of altered gait. Because the Veteran has not raised, and the record does not reasonably raise, entitlement to direct service connection, the Board’s adjudication will consider only entitlement to secondary service connection. The question for the Board is whether the Veteran has current bilateral hip disabilities and a right knee disability that are proximately due to or the result of or are aggravated by service-connected left knee and spine disabilities. The record clearly shows the Veteran has current bilateral hip and right knee arthritis, as noted in his VA treatment records and most recent VA examination in November 2018. He also had a right hip arthroplasty in December 2016 and right knee arthroplasty in August 2017 as the result of the increasing severity of his symptoms. During service, the Veteran was in a motor vehicle accident that resulted in multiple injuries, including a left knee injury that was followed by chronic pain and bursitis. The record does not show, and the Veteran does not contend, that his current bilateral hip disabilities or his right knee disability are the direct result of this accident. Nor have these conditions been continuous or recurrent since service, as the medical evidence of record documents complaints of hip pain dating back to as early as January 2004, decades after the Veteran’s discharge. Rather, the Veteran asserts that his current bilateral disabilities have been caused or aggravated by his service-connected left knee and spine disabilities, to include as a result of altered gait due to these conditions. The Board concludes that, while the Veteran has a current right knee and bilateral hip disabilities, the preponderance of the evidence is against finding that the Veteran’s disabilities are proximately due to or the result of, or aggravated by, his service-connected disabilities. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). A January 2014 VA examination diagnosed right knee chondrocalcinosis and tricompartmental osteoarthritis, as well as bilateral osteoarthrosis of the hips and sacroiliac joints. The examiner opined the right knee and bilateral hip conditions were not at least as likely as not caused by the Veteran’s left knee chondromalacia. In reaching this opinion, the examiner stated there was no evidence in the medical literature that would lead one to believe chondromalacia in one knee would cause chronic hip and sacroiliac joint arthrosis, conditions he describes as the result of long-term wear and tear. The examiner likewise indicated there was no evidence in the medical literature or his personal experience to show chondromalacia patella in one knee is a major cause of osteoarthrosis in the contralateral knee. Finally, the examiner notes the Veteran has a metabolic disease causing pseudogout or chondrocalcinosis in his knees, which is not service-connected. The examiner provided a medical opinion supported by adequate rationale based on a review of the Veteran’s history and the examiner’s medical experience and research. See Nieves-Rodrigues v. Peake, 22 Vet. App. 295 (2008). However, he addressed causation without providing an opinion as to whether the Veteran’s service-connected knee disability aggravated his right knee or bilateral hip disabilities. Therefore, though this opinion is entitled to probative weight regarding causation, it is of no probative value on the issue of aggravation. Furthermore, at his December 2017 Board hearing, the Veteran asserted that his disabilities may also be related to his service-connected back disabilities or altered gait caused by these disabilities along with his service-connected left knee disability. These theories of entitlement were not considered by the January 2014 examiner, rendering his opinion inadequate to allow the Board to adjudicate the issues. For this reason, the Board remanded this matter for additional development in March 2018. A November 2018 VA examiner likewise opined that the Veteran’s right knee and bilateral hip conditions were not at least as likely as not related to or aggravated by his service-connected left knee and spine conditions. As rationale, the examiner indicated there is no medical literature or research documenting gait alteration due to back or knee pain as a cause hip pain or arthritis, nor as a cause of contralateral knee pain. The examiner likewise asserted there was no medical research showing altered gait as an aggravating factor of hip or knee pain, specifically citing multiple studies in the past of polio patients that failed to show increased hip or knee pain as the result of changes in gait. Rather than being secondary to service-connected disabilities, the examiner opines the Veteran’s hip condition is likely related to age and activities after his October 1978 discharge, noting osteoarthritis and arthoplasty surgery are not unusual in his age group. Likewise, he asserts the Veteran’s right knee condition is likely due to activities over the 40 years since discharge, age, and mild obesity. The examiner’s report is competent and credible, as the report was based on a review of the Veteran’s medical records and an in-person examination of the Veteran and is therefore entitled to significant probative weight. See Nieves-Rodriguez, 22 Vet. App. at 304. The Veteran believes his bilateral hip and right knee disabilities are proximately due to, the result of, or aggravated beyond their natural progression by service-connected left knee and spine disabilities. 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 anatomical relationships outside the competence of the Veteran as the record does not show 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). (Continued on the next page)   Consequently, the Board gives more probative weight to the November 2018 VA examiner’s opinion. For these reasons, the Board finds the preponderance of the evidence is against entitlement to service connection for bilateral hip and right knee disabilities, to include as secondary to service-connected left knee and spine disabilities. Therefore, the benefit-of-the-doubt doctrine does not apply, and service connection is not warranted. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). M. HYLAND Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Pitman, Associate Counsel 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.