Citation Nr: 20046447 Decision Date: 07/10/20 Archive Date: 07/10/20 DOCKET NO. 14-15 285A DATE: July 10, 2020 ORDER Entitlement to service connection for multiple myeloma to include as due to exposure to herbicide agents and chemical hazards is denied. Entitlement to compensation under 38 U.S.C. § 1151 for left hip replacement, also claimed as left leg shortness, is denied. Entitlement to compensation under 38 U.S.C. § 1151 for left knee degenerative joint disease (DJD) secondary to left hip replacement is denied. Entitlement to compensation under 38 U.S.C. § 1151 for lumbar spine DJD with pinched nerve secondary to left hip replacement is denied. Entitlement to compensation under 38 U.S.C. § 1151 for right knee DJD secondary to left hip replacement is denied. FINDINGS OF FACT 1. The competent evidence of record does not show that the Veteran’s current multiple myeloma was noted during his active service or that it is related to service, nor does it show he was exposed to herbicide agents during his active service while he was stationed in Okinawa. 2. The VA physicians exercised the degree of skill and care ordinarily required in diagnosing and treating the Veteran’s left hip condition, including performing a left total hip arthroplasty and subsequent revision; the complications the Veteran experienced were not reasonably unforeseeable, but are known potential complications that were disclosed to the Veteran in obtaining his consent to the procedures; none of the residuals the Veteran experienced, including a left leg shortening, were an event not reasonably foreseeable. 3. The Veteran is not service-connected for a left hip replacement or any residuals thereof, including pursuant to 38 U.S.C. § 1151, so secondary service connection is not a viable theory. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for multiple myeloma to include as due to exposure to herbicide agents and chemical hazards have not been met. 38 U.S.C. §§ 1110, 5103(a), 5103A, 1131, 1112, 1113; 38 C.F.R. §§ 3.303, 3.307, 3.309. 2. The criteria for entitlement to compensation under 38 U.S.C. § 1151 for left hip replacement, also claimed as left leg shortness, have not been met. 38 U.S.C. §§ 1151, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.361. 3. The criteria for entitlement to compensation under 38 U.S.C. § 1151 for left knee DJD secondary to left hip replacement have not been met. 38 U.S.C. §§ 1151, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.310, 3.361. 4. The criteria for entitlement to compensation under 38 U.S.C. § 1151 for lumbar spine DJD with pinched nerve secondary to left hip replacement have not been met. 38 U.S.C. §§ 1151, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.310, 3.361. 5. The criteria for entitlement to compensation under 38 U.S.C. § 1151 for right knee DJD secondary to left hip replacement have not been met. 38 U.S.C. §§ 1151, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.310, 3.361. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1975 to March 1976. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from September 2011 and February 2018 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). In the September 2011 rating decision, the RO denied service connection for multiple myeloma. The Veteran timely appealed the decision. The Veteran testified before a Veterans Law Judge at a March 2015 Board Hearing. While the Veterans Law Judge before whom he testified is no longer with the Board, the Veteran has indicated that he does not desire a new hearing. See July 2017 response form. However, a transcript of the hearing is of record, and the Board has considered it. In a January 2018 Board Decision, service connection for multiple myeloma was denied. The Veteran appealed to the United States Court of Appeals for Veterans Claims (Court). The parties filed a November 2018 Joint Motion for Remand (JMR) which the Court granted in a December 2018 Order. The order vacated the January 2018 Board Decision and remanded the matter for additional proceedings consistent with the JMR. In the February 2018 rating decision, the RO denied entitlement to compensation under 38 U.S.C. §§ 1151 for left hip replacement, left knee DJD, right knee DJD, and lumbar spine DJD. The Veteran timely appealed. All five claims (the myeloma claim and the four 1151 claims) then came before the Board. A September 2019 Board Remand directed that additional development be performed by the RO to ensure the issues raised in the JMR could be adequately addressed and to remedy inadequacies in the record with respect to the section 1151 claims. In conducting the requested additional development and readjudication, the RO has substantially complied with the Board’s remand instructions with respect to the above-listed claims, so the Board may proceed to the merits of those claims. See Stegall v. West, 11 Vet. App. 268, 271 (1998); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (noting that Stegall requires substantial compliance with remand orders, rather than absolute compliance). 1. Entitlement to service connection for multiple myeloma to include as due to exposure to herbicide agents and chemical hazards The Veteran is seeking entitlement to service connection for multiple myeloma, as due to herbicide exposure and exposure to chemical hazards. Specifically, the Veteran claims in several statements of record that that his myeloma stems from Agent Orange and benzene exposure during service. Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131. Generally, the evidence must show: (1) the existence of a present disability; (2) 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. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995). Certain chronic diseases are subject to presumptive service connection if manifest to a compensable degree within one year from separation from service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Moreover, for such chronic diseases, an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309(a). See 38 C.F.R. § 3.303 (b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2014). Service connection is warranted for a veteran who has been exposed to a toxic herbicide agent during active military service (subject to the requirements of 38 C.F.R. § 3.307(a)) for diseases such as chloracne or other acneform diseases consistent with ischemic heart disease, Type 2 diabetes, Hodgkin’s disease, non-Hodgkin’s lymphoma, B-cell leukemias, porphyria cutanea tarda, prostate cancer, soft-tissue sarcomas, early-onset peripheral neuropathy, Parkinson’s disease, chloracne and respiratory cancers, and as potentially relevant here, multiple myeloma. 38 C.F.R. § 3.309(e). In this case, after reviewing all evidence currently of record, the Board determines that service connection for myeloma is not warranted because the evidence does not show that the Veteran’s myeloma is related to or had its onset during his service or within a year after separation. First, while multiple myeloma is a disorder that may be presumed related to toxic herbicide agent exposure during the Veteran’s time in service under §3.309, he served in Okinawa, Japan - not in the Republic of Vietnam, the Korean Demilitarized Zone, or a Royal Thai Air Force base. Thus, he is not presumed to have been exposed to Agent Orange in service under §3.309. Despite the presumption of exposure to herbicide agents such as Agent Orange, the Veteran may still show actual exposure with competent evidence. The greater weight of the evidence is against finding that the Veteran was exposed to herbicide agents (as that term is defined in the applicable regulations) during his active service, particularly including while he was stationed in Okinawa. The Veteran has alleged that he was exposed to herbicide agents (e.g., Agent Orange) during his service in Okinawa. See, e.g., September 2017 Appellant’s Brief. He has submitted various news articles, prior Board decisions, and printouts of web pages to support his contention. Most of the articles and other information submitted involved reports and allegations regarding the storage of chemicals, including herbicide agents, and alleged exposures of United States military personnel to those chemicals. In general, the articles do not contain reliable, firsthand information regarding whether particular chemicals were stored or used in or near Okinawa or, if so, what those chemicals were. The Veteran also submitted a January 2013 report prepared for the Office of the Deputy Under Secretary of Defense by a consulting firm that specifically addressed the question of whether herbicide agents were transported to Okinawa, tested and evaluated there, were used on perimeter vegetation around military installations, were stored in Okinawa prior to shipment to Johnston Island, or were buried in Okinawa as a means of disposal. See January 2013 Investigation into the Allegations of Herbicide Orange on Okinawa (hereinafter “January 2013 Investigative Report” or the “Report”). The Report was requested due to “an increasing number of US veterans alleging exposure to Herbicide Orange while service in the US military at military installations in Okinawa during the Vietnam Era.” A number of specific allegations, including allegations similar to those made by the Veteran, were investigated by the consultants. The Report concludes: “[A]fter an extensive search of all known and available records, there were no documents found that validated the allegations that Herbicide Orange was involved in any of these events, nor were there records to validate that Herbicide Orange was shipped to or though, unloaded, used, or buried on Okinawa.” The Report provides extensive evidence and analysis supporting its conclusions. Importantly, the Report notes the difference between commercial herbicides and tactical herbicides (e.g., Agent Orange, Agent Purple), only the latter of which are “herbicide agents” as used in the regulations applicable here. As to the allegation that herbicide agents (tactical herbicides) were stored at Okinawa, the available record “refuted the statement that 25,000 drums of Herbicide Orange were stored on Okinawa prior to shipment to Johnston Island in 1972.” Likewise, although there was an environmental cleanup of areas around Okinawa, the Report reviewed available documentary and other evidence to conclude that there was no evidence that herbicide agents (tactical herbicides such as Agent Orange) were disposed of there, as opposed to commercial pesticides and other chemicals. The other allegations related to herbicide agents were also found to be baseless. The Report noted that there were “no records validating allegations that Herbicide Orange was transported to, used, stored, or buried in Okinawa.” See January 2013 Investigative Report. The January 2013 Investigative Report provides substantial evidence against the Veteran’s claim. The Report is thorough and carefully documented and sourced. Moreover, it references and evaluates several of the news articles and other reports submitted by the Veteran (including the 1993 report referenced by the Veteran) and finds that the reports were either based on later recollections by Veterans who did not have specific knowledge to identify the chemicals involved in the incidents they witnessed or on unreliable hearsay that was contradicted by contemporaneous documents. As noted, when the actual records were evaluated, including environmental evaluations and other scientific investigations into the lay reports of chemicals presumed to be herbicide agents, the evidence failed to validate the various witness statements. The record also includes a September 2016 Formal Finding of a Lack of Information Required to Verify Herbicide Exposure. The Formal Finding concluded that the incidents provided by the Veteran are without merit and are unverifiable by records reviewable by JSRRC. The greater weight of the evidence is against finding that the Veteran was exposed to herbicide agents (e.g., Agent Orange) during his active service. Therefore, the presumptions related to such exposures are inapplicable to the Veteran’s claim. Next, although he is not presumed to have been exposed to herbicide agents and the evidence is against finding that he was actually exposed to herbicide agents as that term is defined in the regulations, the Veteran is not precluded from establishing service connection for his myeloma with proof of actual direct causation as due to active duty service (to include alleged exposure to various chemicals containing benzene as alleged by the Veteran). See Combee v. Brown, 34 F.3d 1039, 1041-42 (Fed. Cir. 1994). However, service connection is also not warranted on this basis. The Veteran has alleged exposure not only to herbicide agents as defined in the regulations, but also to other chemicals and toxic substances. See September 2014 VA 21-4138 (“Okinawa, Japan was at this time an Environmental Hazards from accelerated ‘PCB’ levels, and other contaminates that were from the pile left over from military occupation from Vietnam War. Being that these chemicals had the ability to become ‘Air Borne’ Agents it would put any service member stationed at Okinawa, Japan and it’s surrounding water ways in ‘High Risk’ category for contracting disease.”). The evidence, including the January 2012 Investigative Report discussed above, does establish the use of commercial herbicides in Okinawa as well as the presence of other chemicals. The in-service element is established with respect to some contaminants (though, again, not herbicide agents such as Agent Orange). The issue is then whether those likely exposures are related to his current condition. While the Veteran’s lay opinion regarding whether the chemicals would have become airborne and, if so, whether they would create any “High Risk” of contracting any particular disease, much less his claimed multiple myeloma, is not entitled to probative weight. There is no evidence the Veteran has the education, knowledge, training, or experience to offer an opinion on those highly technical subjects. Therefore, the Board will rely on the competent evidence of record regarding whether any such exposures are related to his current multiple myeloma. The Veteran’s service treatment records show no treatment for or symptoms of myeloma or any bone marrow disease in service or at his separation exam in March 1976, or within the presumptive one-year period after separation. The Veteran was diagnosed with myeloma in April 2011. During this thirty-five year gap, the Veteran displayed no signs or symptoms of this condition. Therefore, based on the clinical evidence of record, service connection cannot be established through continuity of symptomatology. The Veteran has submitted treatment records dating from 2011 to the present. A current disability is conceded. However, the Veteran’s initial diagnosis of myeloma is decades after he left service. Moreover, he has never truly asserted that such symptoms have existed since service. Therefore, continuous symptoms have not been established based on the evidence of record or the Veteran’s statements. See Jandreau v. Nicholson, 492 F.3d 1372, 1376 (Fed. Cir. 2007). Despite the lack of continuous symptoms, service connection may still be warranted if the evidence otherwise indicates a relationship between his current disorder and his active duty service. However, there is no medical nexus between the Veteran’s active duty and his current diagnosis. A February 2017 VA opinion was sought to determine the etiology of the Veteran’s myeloma, pursuant to the Remand order. The goal was to determine the likelihood that the Veteran’s service, particularly his asserted exposure to herbicides and/or benzene, caused his myeloma. The examiner explained that there is no research indicating a strong correlation between chemical exposure and multiple myeloma. In fact, the examiner pointed to studies conducted by the American Cancer Society indicating that while there is a possibility of an increase of incidence of multiple myeloma and other blood disorders with exposure to benzene, it is at best a possibility. The examiner thus opined that it was less likely that the Veteran’s myeloma is the result of a disease or injury incurred during service. In a June 2014 private medical opinion submitted by the Veteran, a physician states that certain exposures increase the probability of developing myeloma, including exposure to certain chemicals. The physician further opines that, if the Veteran was exposed to Agent Orange, there is a probability that it could have served as a potential etiologic agent. Similar to the negative nexus opinion supplied by the Veteran’s February 2017 VA examiner, this opinion intimates a possible etiological likelihood. However, neither opinion approaches the required burden of proof – that it is at least as likely as not that the Veteran’s current disorder was caused by an in-service injury, disease, or event. Moreover, the opinion relies on exposure to herbicide agents (i.e., tactical herbicides such as Agent Orange) which has not been established (see above), rather than commercial herbicides and other chemicals containing benzene. Therefore, the opinions do not warrant probative value on that basis as well. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (holding that a medical opinion obtains probative weight from “factually accurate, fully articulated, sound reasoning for the conclusion”); see also Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (“An opinion based upon an inaccurate factual premise has no probative value.”). The Board also notes literature submitted by the Veteran indicating an increased risk of cancer in Vietnam veterans exposed to benzene-containing chemicals (including herbicide agents, commercial herbicides, or other chemical substances). Information contained within treatises is generally too abstract to prove the nexus element of a service-connection claim, although it is possible that a treatise might “discuss generic relationships with a degree of certainty” that would allow a finding of “plausible causality based upon objective facts.” See Sacks v. West, 11 Vet. App. 314, 316-17 (1998). These articles are entitled to no independent probative value in this case as they discuss general relationships and do not address the particular exposures established in this case. To the extent experts have discussed these articles and related the information contained in them to this particular case, the Board has considered the article and given them appropriate probative value in the context of those opinions. The February 2017 VA examiner failed to specifically address the literature cited by the Veteran as the Board requested in its October 2015 Board Remand. Therefore, the Board requested that the RO obtain an additional opinion addressing that literature. Pursuant to that request, VA obtained a February 2020 VA Examiner’s Opinion. The examiner reviewed the medical literature referenced by the Veteran and the June 2014 private medical opinion before concluding that the Veteran’s multiple myeloma was less likely than not that incurred in or caused by his military service, including alleged exposure to “benzene or other petroleum products.” The examiner acknowledged that there is scientific evidence that benzene may be a carcinogen and that exposure to “radiation, organic chemicals (such as benzene), herbicides and insecticides may play a role” in the development of various cancers including multiple myeloma. However, the examiner noted that the literature supports linking such exposures to acute myelogenous leukemia. The weight of the scientific evidence, the examiner opined, was against finding that the Veteran’s multiple myeloma “was related to service exposure to benzene.” This opinion is entitled to probative weight as it addresses exposure to benzene that is consistent with the Veteran’s established exposures and explains why those exposures are not likely to have caused the Veteran’s condition. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (“most of the probative value of a medical opinion comes from its reasoning”); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A] medical opinion…must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions.”). The greater weight of the evidence is against finding that the Veteran’s alleged in-service exposures caused his later-diagnosed multiple myeloma. The only opinion supporting a causal link was not stated to the requisite degree of medical certainty, but instead posited a possible relationship. There are negative opinions that are entitled to probative value and which are stated to the requisite degree of medical certainty. The greater weight of the evidence is against finding an etiological relationship between the alleged in-service exposures and the current disability. Moreover, since the Veteran did not develop myeloma within the one-year statutory period, presumptive service connection cannot be granted. In arriving at this conclusion, the Board recognizes the 2014 statements, 2015 hearing testimony, and 2017 statements of the Veteran relating his current disorder to storage of Agent Orange on Okinawa, and the use of benzene heat tablets during service. Particularly, the Board notes the Veteran’s hearing testimony indicating that he and other service members developed a rash from a substance encountered on vegetation in Okinawa. The Board has relied on this testimony in concluding that the Veteran did have some type of chemical exposures, including potentially to commercial herbicides or other chemical substances containing benzene. The issue then, is whether that exposure is related to his current condition. As noted above, the competent medical evidence is against finding an etiological link. The Federal Circuit has held that “[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional.” Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (quoting Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In this case, however, the Veteran is not competent to testify regarding the etiology of multiple myeloma or any other blood disorder. See Jandreau, 492 F.3d 1372 at 1377, n.4. Because such disorders are not diagnosed by unique and readily identifiable features, they do not have a simple identification that a layperson is competent to make. In addition, a qualified medical opinion is required to link the Veteran’s current symptoms to any event occurring in service, especially when it relates to a blood disorder. The Veteran’s private opinion and the VA opinions do not make such a link. Therefore, the lay statements of belief that the Veteran’s multiple myeloma is related to his time in service, especially his exposure to Agent Orange and/or benzene, are found to lack competency and, so, any probative value. The greater weight of the evidence is against the Veteran’s claim of entitlement to service connection for multiple myeloma. Entitlement to service connection for multiple myeloma is denied. 1151 Eligibility 2. Entitlement to compensation under 38 U.S.C. § 1151 for left hip replacement, also claimed as left leg shortness The Veteran seeks entitlement to benefits under 38 U.S.C. § 1151 for a left hip replacement and residuals thereof allegedly incurred as a result of VA treatment. The preponderance of the evidence is against the claim and the appeal is denied. Under 38 U.S.C. § 1151, compensation may be paid for a qualifying additional disability or qualifying death from VA treatment or vocational rehabilitation as if the additional disability or death were service connected. 38 U.S.C. § 1151. A review of the record reveals that the Veteran submitted his § 1151 claim via a November 2017 VA Form 21-526EZ and that all relevant treatment occurred in or after 2005. Thus, the claim must be adjudicated under only the current version of 38 U.S.C. § 1151, which requires a showing of fault on the part of VA. See 69 Fed. Reg. 46,426 (Aug. 3, 2004) (including the codification of 38 C.F.R. § 3.361 which applies to such claims filed on or after October 1, 1997, and revising 38 C.F.R. § 3.358 to state that the section only applied to claims filed before October 1, 1997). Under 38 U.S.C. § 1151, a disability is a qualifying additional disability, if the additional disability was not the result of the Veteran’s willful misconduct, and was caused by hospital care, medical or surgical treatment, or examination furnished the Veteran when the proximate cause of the disability or death was: (A) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care, medical or surgical treatment, or examination; or (B) an event not reasonably foreseeable. Section 1151 contains two causation elements, the disability must not only have been caused by the hospital care or medical treatment but it must also be proximately caused by VA’s fault. See Viegas v. Shinseki, 705 F.3d 1374, 1377-78 (2013). In order for the appellant to be eligible for compensation under 38 U.S.C. § 1151 due to VA treatment, the evidence must establish that he sustained additional disability and that this additional disability is etiologically linked to the VA treatment by the appropriate standard under 38 U.S.C. § 1151. If there is no competent evidence of additional disability or no evidence of a nexus between the hospitalization, medical or surgical treatment, or examination and the additional disability or death of the Veteran; the claim for compensation under 38 U.S.C. § 1151 must be denied. In determining whether a Veteran has an additional disability, VA compares the Veteran’s condition immediately before the beginning of the hospital care or medical or surgical treatment upon which the claim is based to the Veteran’s condition after such care or treatment. VA considers each involved body part or system separately. 38 C.F.R. § 3.361(b). To establish causation, the evidence must show that the hospital care or medical or surgical treatment resulted in the Veteran’s additional disability. Merely showing that a Veteran received care or treatment and that the Veteran has an additional disability does not establish cause. 38 C.F.R. § 3.361(c)(1). Hospital care or medical or surgical treatment cannot cause the continuance or natural progress of a disease or injury for which the care or treatment was furnished unless VA’s failure to timely diagnose and properly treat the disease or injury proximately caused the continuance or natural progress. 38 C.F.R. § 3.361(c)(2). An additional disability or death caused by the Veteran’s failure to follow medical instructions will not be deemed to be caused by hospital care, medical or surgical treatment or examination. 38 C.F.R. § 3.361(c)(3). To establish that carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA’s part in furnishing hospital care, medical or surgical treatment, or examination proximately caused a Veteran’s additional disability or death, it must be shown that the hospital care or medical or surgical treatment caused the Veteran’s additional disability or death; and (i) VA failed to exercise the degree of care that would be expected of a reasonable health care provider; or (ii) VA furnished the hospital care or medical or surgical treatment without the Veteran’s informed consent. 38 C.F.R. § 3.361(d)(1). Determinations of whether there was informed consent involve consideration of whether the health care providers substantially complied with the requirements of 38 C.F.R. § 17.32. Minor deviations from the requirements of 38 C.F.R. § 17.32 that are immaterial under the circumstances of a case will not defeat a finding of informed consent. 38 C.F.R. § 3.361(d)(1). Whether the proximate cause of a Veteran’s additional disability or death was an event not reasonably foreseeable is in each claim to be determined based on what a reasonable health care provider would have foreseen. 38 C.F.R. § 3.361(d)(2). The event need not be completely unforeseeable or unimaginable but must be one that a reasonable health care provider would not have considered to be an ordinary risk of the treatment provided. In determining whether an event was reasonably foreseeable, VA will consider whether the risk of that event was the type of risk that a reasonable health care provider would have disclosed in connection with the informed consent procedures of 38 C.F.R. § 17.32. 38 C.F.R. § 3.361(d)(2). The Veteran has alleged that he underwent a September 2005 left hip replacement at a VA facility and, because the initial procedure was unsuccessful, he “had to have a Revision procedure that was supposed to correct certain Negligent things that happened during the first procedure.” See November 2017 Correspondence from Veteran. He contends that, after the procedure, his left leg was one quarter inch shorter which, together with other residuals of the procedure, resulted in constant chronic pain in his left hip and lower back, an altered gait, and the deterioration of his left and right knees. Id.; December 2017 VA 21-4138 (discussing the procedure and residuals, plus indicating a one and one sixteenth (1 and 1/16) inch shortening of his left leg due to the left hip replacement). During his appeal, the Veteran has clarified that he believes the shortening of his leg was the result of the hip replacement surgery and that the shortening of his leg was not reasonably foreseeable and caused him considerable hardship. See March 2018 Addendum to VA Form 21-0958. The basic facts are as follows. The Veteran had a motor vehicle accident in April 2005 resulting in a left hip dislocation and fracture. He was transported to a private hospital and underwent operative treatment of the fracture at that private hospital. The Veteran initially “did okay post-operatively, but then progressively began getting worse with symptomatology and pain in his left hip.” February 2018 VA Examination (providing a detailed history of the Veteran’s left hip injuries, surgeries, and post-operative residuals). The Veteran’s left hip condition continued to deteriorate and a left total hip arthroplasty was offered as an option. The Veteran was informed that the risks of repeat hip surgery included nerve and blood vessel injury, infection, dislocation, failure, and infection again. Id. The Veteran was diagnosed with traumatic arthritis of the left hip and femoral head necrosis as residuals of the motor vehicle accident. Id. (quoting treating records from August and September 2005). The Veteran underwent the left total hip arthroplasty in September 2005 with a subsequent infection and revision. The Veteran had another infection after the revision and had to undergo long-term antibiotic therapy. The surgeries and complications thereof resulted in a shortening of the left leg that caused limping and consequent hip pain. Id. The Veteran does not dispute these basic facts. He contends, however, that there were violations of the standard of care during the surgeries or, alternatively, that the shortening of the left leg after the surgeries was not reasonably foreseeable. He has not submitted any medical opinions in support of his claims. The Veteran is a lay person and these are complex medical questions which require knowledge of the standard of care for hip surgery, the precise etiology and cause of the Veteran’s residuals which requires expert knowledge of anatomy, pathology of hip disorders, and an understanding of the particulars of the various surgeries the Veteran underwent, including the foreseeable complications of such surgeries. Because the Veteran lacks the education, training, and/or experience to make these highly technical judgments, his statements and beliefs regarding these issues are not competent evidence in this medically complex case and, so, are not entitled to probative value. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); King v. Shinseki, 700 F.3d 1339, 1344-45 (Fed. Cir. 2012); see also Jandreau, 492 F.3d at 1377. Therefore, in evaluating the Veteran’s claims, the Board will rely on the competent medical evidence of record. The Board, however, has considered the Veteran’s subjective reports of symptoms, particularly as they illuminate or underscore the medical opinions of record. The RO obtained an opinion from a VA examiner. See February 2018 VA Examination. The examiner opined that the Veteran’s left hip condition did not worsen as a result of treatment by VA in September 2005. The examiner noted that the Veteran had intractable pain, necrosis of the tissue from the initial injury, and an infected joint prior to the September 2005 surgery. The examiner opined that the “hip replacement surgery was indicated, performed appropriate to the circumstances, and helped improve, rather than worsen, any disability.” The examiner further opined, with a thorough rationale, that there was not any failure to follow appropriate standard of care by VA personnel. For example, the possibility of infection was discussed with the patient prior to the surgery as was the possibility of failure of the revision, particularly given the condition of the left hip at the time of surgery. The examiner opined that the surgeries helped the Veteran and that the residuals that the Veteran experienced were due to the initial injury rather than to the medical/surgical treatment of the injury. The examiner also opined that there was no failure to timely diagnose any of the multiple complications and the Veteran’s condition did not go unrecognized or untreated such that it progressed to cause disability. Instead, he was appropriately referred to specialists in a timely manner, results of diagnostic testing were timely communicated, and the Veteran’s condition was otherwise promptly assessed and treated throughout the course of his surgeries and post-operative care. The examiner opined that, despite complications, the complications “were well within the realm of known risks and the records document clearly that the risks were discussed at each step of the care process.” Id. The Board requested that an additional opinion specifically addressing the Veteran’s contention that his left leg shortening was an event that was not reasonably foreseeable. Therefore, VA obtained a March 2020 VA examiner’s opinion. The examiner opined that the Veteran’s left leg shortness was a result of the hip surgeries and, further, that it is less likely than not that the VA failed to exercise a degree of care that would be expected of a reasonable health care provider. The examiner explained that, while the Veteran did experience complications from the surgery, those complications were appropriately addressed by VA medical care providers. The opinion did not, however, address the foreseeability of the left leg shortening. Therefore, a March 2020 VA examiner’s addendum opinion was obtained. The VA examiner noted that the Veteran was apprised of the risks of the procedure, including the possibility of infection. The examiner opined that the complications that did arise were treated promptly and appropriately. He then concluded that “it is less likely than not that the left hip replacement, also claimed as left leg shortness, caused by VA treatment is due to an event not reasonably foreseeable.” The VA examiners’ various opinions establish that the medical care that the Veteran received from VA met the standard of care and did not involve carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care, medical or surgical treatment, or examination to the Veteran. Therefore, entitlement to compensation under 38 U.S.C. § 1151 for residuals of the left hip surgeries is not warranted on the basis of any alleged negligence. The Veteran has argued that, in the alternative, the shortening of his leg was the result of the hip replacement surgery and that the shortening of his leg was not reasonably foreseeable and caused him considerable hardship. See March 2018 Addendum to VA Form 21-0958. The greater weight of the evidence is also against this theory of entitlement. As discussed above, the only competent opinions addressing this issue are against the claim. The February 2018 VA examiner’s opinion stated: “While there were complications, they were well within the realm of known risks and the records document clearly that the risks were discussed at each step of the care process.” The March 2020 VA examiner’s addendum opinion stated that “it is less likely than not that the left hip replacement, also claimed as left leg shortness, caused by VA treatment is due to an event not reasonably foreseeable.” These opinions, particularly taken together, establish that the Veteran’s residuals of the left hip surgeries, to include left leg shortness, were not proximately caused by an event not reasonably foreseeable. See Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (medical reports must be read as a whole and in the context of the evidence of record); see also Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (the fact that the rationale provided by an examiner “did not explicitly lay out the examiner’s journey from the facts to a conclusion,” did not render the examination inadequate). The Veteran has not submitted any competent evidence to contradict these examiners’ opinions. The VA examiners’ opinions are adequate to decide the matter and are against the Veteran’s claims. Entitlement to compensation under 38 U.S.C. § 1151 for left hip replacement, also claimed as left leg shortness, is denied. 3. Entitlement to compensation under 38 U.S.C. § 1151 for left knee DJD secondary to left hip replacement 4. Entitlement to compensation under 38 U.S.C. § 1151 for right knee DJD secondary to left hip replacement 5. Entitlement to compensation under 38 U.S.C. § 1151 for lumbar spine DJD with pinched nerve secondary to left hip replacement The Veteran has claimed that he has left and right knee degenerative joint disease and lumbar spine degenerative joint disease that was caused by the left hip replacement which, he believes, should be considered service-connected pursuant to 38 U.S.C. § 1151. Because the claim of entitlement to compensation under 38 U.S.C. § 1151 for left hip replacement, also claimed as left leg shortness, was denied, the Veteran’s theory of secondary service-connection (via Section 1151) is not viable. There is no allegation, nor anything in the record to support, that any left or right knee condition, to include DJD, or any lumbar spine condition, proximately resulted from any VA care, rather than from the residuals of the left hip injury and surgeries, to include altered gait and left leg shortness. Because the Board has determined there was no negligence or lack of informed consent with respect to the left hip surgeries and that none of the complications, including leg shortening, resulting from those surgeries were an event not reasonably foreseeable, the Veteran’s claim for compensation for left and right knee DJD and for lumbar spine degenerative joint disease as secondary to the left hip replacement necessarily fails. Entitlement to compensation under 38 U.S.C. § 1151 for left and right knee DJD and lumbar spine degenerative joint disease secondary to left hip replacement is denied. Duties to Notify and Assist The Veteran submitted boilerplate argument on a variety of duty to notify and assist issues, but did not raise any specific alleged deficiencies. Construing the Veteran’s pleadings liberally, in his March 2018 Addendum to VA Form 21-0958, the Veteran raised the issue of whether the February 2018 VA examiner’s opinion adequately addressed the issue of foreseeability of the left leg shortening. VA obtained an additional opinion directly addressing that issue on remand. The Veteran has not questioned the adequacy of that opinion. The Board finds that the March 2020 VA examiner’s opinion addressing foreseeability, particularly when interpreted in light of the entire record, is adequate. The Veteran has not raised any other specific 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 a duty to assist argument). Therefore, the Board does not need to discuss VA’s compliance with the duties to notify and assist. MICHELLE L. KANE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Kerry Hubers 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.