Citation Nr: 21004674 Decision Date: 01/27/21 Archive Date: 01/27/21 DOCKET NO. 14-03 356 DATE: January 27, 2021 ORDER Entitlement to service connection for bilateral hip osteoarthritis, status post hip replacements, is denied. FINDING OF FACT The Veteran’s bilateral hip osteoarthritis, status post hip replacements, was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease. CONCLUSION OF LAW The criteria for service connection for bilateral hip osteoarthritis, status post hip replacements, 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. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from October 1966 to October 1972, and from June 1976 to June 1985. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an April 2012 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). This appeal has been advanced on the Board’s docket pursuant to 38 C.F.R. § 20.900. 38 U.S.C. § 7107 (a)(2). In October 2017 and January 2019, the Board remanded the claims for service connection for bilateral hip replacements for further development. Service Connection 1. Entitlement to service connection for bilateral hip osteoarthritis, status post bilateral hip replacements The Veteran seeks service connection for bilateral hip replacements. The Veteran contends that gait abnormalities from his service-connected bilateral knee and left foot disabilities proximately caused or aggravated his hip osteoarthritis. Alternatively, he contends that the physical demands and resulting wear and tear on his hips during active service are related to his current bilateral hip arthritis. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Certain chronic diseases will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Secondary service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310 (a). Secondary service connection includes the concept of aggravation of a nonservice-connected disability by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). Service treatment records reflect shoulder, back, knee, and foot pain complaints. However, service treatment records are notably silent for complaints, diagnosis, or treatment of a hip condition. In August 1977, the Veteran sought treatment for trauma to the left foot. In May 1978, he sought treatment for low back pain. In June 1982, the Veteran sought treatment for pain in the right shoulder and right knee. In March 1985, the Veteran appeared for an orthopedic consultation of his left knee. Treatment providers assessed a left knee inversion, with a small amount of swelling. A March 1985 physical profile board proceeding showed the Veteran injured his left knee. In the May 1985 report of medical history, the attending physician noted chronic bilateral knee pain, and leg cramps after running with no sequalae. In April 2004, the Veteran underwent a right total hip arthroplasty. Treatment providers noted severe osteoarthritis of the right hip with large osteophyte of the femoral head and neck as well as the acetabulum. In April 2005, the Veteran underwent a left total hip arthroplasty. Treatment providers noted left hip osteoarthritis, with pain that affected quality of lifestyle and decreases in activities of daily living. In October 2013, the Veteran appeared for an intake visit. Treatment providers noted a medical history of hip replacement bilaterally. In January 2018, the Veteran underwent a VA examination. The Veteran reported that he had hip replacements for osteoarthritis in 2004 and 2005. He reported a slight increase in pain in his hips with weather changes. The VA examiner diagnosed bilateral hip replacement. The examiner opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The January 2019 Board remand found this opinion inadequate, because the rationale reflects the opinion was based solely on the absence of documented treatment which renders it inadequate. In December 2019, the Veteran underwent a VA examination. The examiner opined the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that hip degeneration is common in older age individuals and with those who have repeated stress on the joint. The examiner noted that lifetime risk for hip osteoarthritis is about 1 in 5 for men and 1 in 4 for women, according to the Centers for Disease Control and Prevention. Additionally, up to half of all cases of hip arthritis may be related to inherited genetics, whether that is a family member with osteoarthritis or simply having genes for poor bone health or hip alignment. Obesity and hip injury are important independent risk factors for hip osteoarthritis. Thus, the examiner concluded the that it is less likely than not that the Veteran’s hip osteoarthritis manifested to a compensable degree within a year of service discharge from either period of active duty. The examiner further opined that the claimed condition is less likely than not (less than 50 percent probability) proximately due to or aggravated by the Veteran’s service-connected disability. The examiner noted that the Veteran alleged that due to altered gait from bilateral knee and left foot injuries, he developed osteoarthritis of the bilateral hips that ultimately required bilateral replacements. The examiner explained that the two conditions are not medically related. The hip condition is a separate entity, and entirely unrelated to the service-connected conditions. The medical literature does not support a medical relationship, and thus a nexus between the hip and knee conditions was not established. The medical literature also does not support aggravation of hip degeneration due to lower extremity conditions. She noted that there is a connection between hip osteoarthritis and abnormal gait. However, the relationship between gait biomechanics and osteoarthritis can be viewed as a chicken-and-egg problem. She explained that it isn’t clearly whether the arthritic changes drive the gait changes, or the gait is causing the arthritis. Therefore, she concluded that it is less likely than not the hip arthritis and replacements were due to or aggravated beyond its natural progression by the Veteran’s service-connected disabilities. Having considered the evidence of record, the Board concludes service connection is not warranted. The Veteran has a current diagnosis of bilateral hip osteoarthritis, status post bilateral hip replacements, as evidenced by treatment records and the December 2019 VA examination. Osteoarthritis is an enumerated condition under 38 C.F.R. § 3.309(a); Walker, 708 F.3d 1331. The evidence of record shows that the Veteran separated from service in 1985 and his initial report of bilateral hip arthritis was not until around 2004, decades after service. His service treatment records do not show complaints of, or treatment for, bilateral hip pain. There also was no diagnosis of bilateral hip arthritis within one year of service. The Board thus concludes that, while the Veteran has bilateral hip arthritis, which is a chronic disease under 38 C.F.R. § 3.309 (a), it was not shown as chronic in service or within a presumptive period, did not manifest to a compensable degree within a presumptive period, and was not noted in service with credible evidence of continuity of symptomatology. The Veteran’s representative contends that the separation exam documented that the Veteran suffered from chronic bilateral knee pain, which is one of the symptoms of osteoarthritis in the hips. While the Veteran is competent to report having experienced symptoms of knee pain since service, he is not competent to determine that these symptoms were manifestations of his current bilateral hip osteoarthritis as the Veteran has not demonstrated the necessary medical expertise. The issue is medically complex, as it requires specialized medical education. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). In this regard, the Board notes that service treatment records attribute the Veteran’s knee complaints to specific knee injuries, and that the Veteran is service-connected for residuals of bilateral knee and left foot disabilities. Service connection for bilateral hip osteoarthritis may still be granted on a direct basis; however, the preponderance of the evidence is against finding that a medical nexus exists between the Veteran’s bilateral hip osteoarthritis and an in-service injury, event or disease. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303. The December 2019 VA examiner opined that the Veteran’s bilateral hip replacements are not at least as likely as not related to an in-service injury, event, or disease. The explained that hip osteoarthritis is a common condition, and that up to half of all cases may be related to genes for poor bone health or poor hip alignment. The Veteran’s representative contends the December 2019 VA examination is inadequate, because the VA examiner did not appear to take into account any of what this veteran did during service, how physical his MOS was, the physical fitness requirement, or that the Veteran served in the military for 21 years. The Board disagrees. The December 2019 examination was generated by a health care professional and the associated reports reflect review of the Veteran’s statements, prior medical history, and records. The reports included etiologic opinions and demonstrated objective evaluations, including the specific periods of active duty for the Veteran. As a result, the Board finds that additional development by way of another medical opinion would be redundant and unnecessary. See 38 C.F.R. § 3.326; Green v. Derwinski, 1 Vet. App. 121 (1991). Therefore, the Board concludes that the appellant was afforded an adequate examination. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Veteran has asserted that his bilateral hip disabilities are related to his service-connected knee or foot disabilities, however, the Board finds service connection is not warranted. The December 2019 VA examiner opined that the Veteran’s bilateral hip replacements are not at least as likely as not related to an in-service injury, event, or disease, including the Veteran’s service-connected bilateral knee and left foot disabilities. The examiner explained that the conditions are entirely unrelated. She also explained that the medical literature did not support a relationship between the Veteran’s bilateral hip disability and his service-connected knee and left foot disabilities. She acknowledged the Veteran’s contention that gait abnormalities caused his hip osteoarthritis, but explained that it isn’t clear whether gait abnormalities cause the osteoarthritis, or the osteoarthritis causes the gait abnormalities. Thus, she concluded it is less likely than not that the Veteran’s bilateral hip osteoarthritis was proximately due to or aggravated beyond its normal course by his service-connected knee and left foot disabilities. While the Veteran believes his bilateral hip replacements are related to an in-service injury, event, or disease, including as a result of abnormal gait from his service-connected disabilities, he is not competent to provide a nexus opinion in this case. This issue is also medically complex, as it requires specialized medical education and knowledge of the interaction between multiple systems in the body. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. In sum, the preponderance of the evidence weighs against finding that the Veteran’s hip disabilities were incurred in service or are otherwise attributable to service. As such, the benefit of the doubt doctrine does not apply, and service connection is not warranted. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). D. JOHNSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Lauritzen, 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.