Citation Nr: 21063650 Decision Date: 10/15/21 Archive Date: 10/15/21 DOCKET NO. 18-31 854 DATE: October 15, 2021 ORDER Service connection for avascular necrosis (AVN) of the left hip is denied. REMANDED Entitlement to special monthly compensation (SMC) based on the need for regular aid and attendance or housebound status is remanded. Entitlement to specially adapted housing is remanded. FINDING OF FACT The Veteran's left hip AVN is not secondary to her service-connected disabilities, explicitly to include those of the left hip and left knee, and is not otherwise related to an in-service injury or disease. CONCLUSION OF LAW The criteria are not met to establish service connection for left hip avascular necrosis due to service or other service-connected disability. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Navy from October 1995 to February 1996. This matter is before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued in November 2017 and December 2017. In January 2019, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of the Veteran's hearing testimony is considered as evidence in this appeal. This appeal was last before the Board in April 2021 at which time additional evidentiary development was requested to comply with due process requirements. For the issue of service connection for left hip AVN, the evidentiary record has been adequately developed in substantial compliance with all prior Board remand instructions and has now been returned to the Board for further appellate review. Additional development remains for the matters of entitlement to SMC and specially adapted housing as described below, and those issues are remanded for further development as described below. Service connection for AVN of the left hip. Initially, the Board must note that service connection is already in effect for multiple left hip disabilities including left hip strain, status post IT band release, limitation of flexion, abduction, adduction and rotation of the left hip, and a surgical scar. Service connection is also already in effect for left lower extremity radiculopathy as associated with the Veteran's separately service-connected back disability. However, the Veteran perfected an appeal as to service connection for a left hip disability in general, then following a prior remand by the Board was granted service connection for the specific left hip disabilities described above. Because diagnosed left hip AVN is shown to have been present during the current appeals period, but service connection for left hip avascular necrosis was not granted, this issue has procedurally remained on appeal and is now addressed on this basis. The Board also notes that this issue was previously listed as "entitlement to service connection for a left hip disability, to include avascular necrosis, (excluding left hip strain, limitation of flexion, abduction, adduction, and rotation)" which remains accurate; however, as AVN is the only identified left hip disability for which service connection has not been granted at this time, the Board has recharacterized the issue as entitlement to service connection for avascular necrosis. The Veteran has not identified another left hip disability other than AVN and those for which service connection has already been granted for which she continues to seek service connection. Although the Veteran described the onset of some hip pain shortly after her discharge from service, she has not described, nor does the record reasonably raise an onset of AVN of the left hip during service. AVN was not diagnosed until in or around 2018, more than 20 years after the Veteran's discharge. Thus, because the Veteran argues that her identified left hip disabilities, including AVN, are secondary to her service-connected left knee disability due to changes in her gait or otherwise compensating for impairment of her surgically replaced left knee joint, the Board's adjudication of the remaining left hip issue will focus on entitlement to service connection on a secondary basis rather than a direct relationship to service. See, e.g., Board hearing transcript, January 2019; VA Form 9, July 2018. In this regard, service connection may be granted for a disability that is proximately due to, or aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310. The question for the Board is whether the Veteran's avascular necrosis is proximately due to or the result of or worsened by another service-connected disability. The Board concludes that, while the Veteran has a current left hip AVN disability, the preponderance of the evidence is against finding that the Veteran's left hip AVN is proximately due to or the result of, or aggravated by, service-connected disability. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). A December 2019 VA examiner opined that the Veteran's left hip AVN is instead due to her frequent use of steroid medication used to treat her nonservice-connected sarcoidosis. The rationale was that use of high-dose corticosteroids, such as prednisone, is a common cause of avascular necrosis. The reason for this is unknown, but one hypothesis is that corticosteroids can increase lipid levels in the blood, reducing blood flow. Other known risk factors for AVN include traumatic injuries such as a dislocation or fracture of the hip, excessive alcohol use, long-term use of bisphosphonate medications, and certain medical treatments such as radiation therapy for cancer or organ transplantation, none of which are applicable in this case. A June 2021 VA examiner further opined that the Veteran's left hip AVN is less likely than not (less than 50 percent probability) due to or the result of her other service-connected hip disabilities because hip strain is not a known cause of AVN. Instead, AVN of the hip is most common with direct damage to the bone vasculature (such as femoral neck fracture) or direct injury of bone or marrow elements (such as radiation, dysbarism, or compression disease) and that "most experts believe that AVN is the result of combined effects of genetic predisposition, metabolic factors, and local factors affecting blood supply such as vascular injury, increased intraosseous pressure, and mechanical stresses. It is generally agreed that there is an interruption of blood circulation within the bone." VA examination, June 2021. The examiner did not find these factors to be present here as due to the Veteran's service-connected disabilities, specifically to include the other service-connected left hip and left knee disabilities. Regarding the potential causation or aggravation of left hip AVN by the Veteran's service-connected left knee disability, the examiner found that it is less likely than not that AVN was caused or aggravated by an antalgic and compensatory gait due to the left knee replacement and pre- or post-operative pain because that type of gait would have been protective concerning the left hip because it would favor the right side, rather than the left side. In other words, the Veteran's left knee replacement would have resulted in avoidance of use of the left hip and a rightward shift of her weight during weightbearing activities would have been more likely to protect the left hip rather than cause harm. VA examination, June 2021. In addition, this examiner found that it is less likely than not that the Veteran's left hip AVN is aggravated or worsened by her other service-connected left hip disabilities, because although the condition of osteonecrosis is often progressive in nature on its own, the Veteran's other left hip conditions are also likely protective in this case because she avoids repetitive impact, high impact or otherwise weightbearing activities of the left hip due to the service-connected left hip strain and limitations of motion. The Veteran believes her left hip impairments collectively were caused by "overcompensating" for her service-connected left knee replacement. VA Form 9, July 2018. 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 the interaction between the bone and vascular systems in the body, their anatomical relationships, and pathology. Therefore, it is outside the competence of the Veteran in this case because the record does not show that she 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). Consequently, the Board gives more probative weight to the medical evidence discussed above. The Veteran has not submitted competent evidence in support of the claimed relationship between her diagnosed AVN and another service-connected disability, nor does the record reflect that the Veteran's left hip AVN was proximately due to or aggravated by another service-connected disability. Considering the evidence in its entirety, the Board finds that the evidence weighs against the claim and service connection for AVN of the left hip must be denied. REASONS FOR REMAND 1. Entitlement to SMC based on the need for regular aid and attendance of another person, or housebound status. The Veteran asserts that she has limitations of mobility that require help with her daily activities. See, e.g., VA Form 9, July 2018. Examinations to determine the Veteran's permanent need for regular aid and attendance or housebound status were performed in April 2017 and March 2019, and are documented within the claims file. However, each of these medical reports describe the level of care required as being based, at least in part, upon conditions for which service connection has not been established (including chronic pain syndrome, bilateral shoulder disability, asthma, allergic rhinitis, essential tremors). The Veteran should be provided an opportunity to report for a VA examination to ascertain the current severity and manifestations of her service-connected disabilities alone as to her actual requirement for personal assistance from others. 38 C.F.R. §§ 3.159, 3.352(a). 2. Entitlement to specially adapted housing. Finally, because the outcome of the examination requested above and its findings as to the functional impact of the Veteran's lower extremity disabilities could significantly impact a decision on the issue of eligibility for specially adapted housing, the issues are found to be inextricably intertwined. A remand of the claim for a specially adapted housing grant is also required. The matters are REMANDED for the following action: Schedule the Veteran for an examination to determine her need for regular aid and attendance or housebound status. The examiner should address only the functional limitations due to the Veteran's service-connected disabilities alone, with specific focus on her actual requirements for the personal assistance of another person or whether the Veteran is substantially confined to her dwelling or immediate premises. For specially adapted housing, the examiner should address the following: (a) Do the Veteran's service-connected lower extremity disabilities "preclude locomotion without the aid of braces, crutches, canes, or a wheelchair"? (b) Does the Veteran have loss of use of one lower extremity together with residuals of organic disease or injury which so affect the functions of balance or propulsion as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair? For both questions, the term "preclude locomotion" means the necessity for regular and constant use of a wheelchair, braces, crutches, or canes as a normal mode of locomotion although occasional locomotion by other methods may be possible. Full and thoroughly explained answers to each of these questions will prevent further delays in adjudication and are appreciated. C. CRAWFORD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. McDonald, 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.