Citation Nr: 21074920 Decision Date: 12/16/21 Archive Date: 12/16/21 DOCKET NO. 17-35 434 DATE: December 16, 2021 ORDER Service connection for right hip disorder is denied. Service connection for left hip disorder is denied. FINDINGS OF FACT 1. A right hip disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service, and arthritis did not manifest within one year of separation from active duty. 2. A left hip disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service, and arthritis did not manifest within one year of separation from active duty. CONCLUSIONS OF LAW 1. The criteria for service connection for right hip disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. 2. The criteria for service connection for left hip disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from June 1970 to June 1992, during part of which he was deployed to the Republic of Vietnam and for which service, among his other medals and decorations, he was awarded the Parachutist Badge and the Bronze Star Medal. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from a disease or injury incurred in active service or that a preexisting injury or disease was aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). Establishing service connection generally requires: (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 in or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Certain chronic diseases such as arthritis may warrant service connection on a presumptive basis if manifested to a compensable degree in a specified period of time post-service. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. That period is usually one year. 38 C.F.R. § 3.307 (a)(3). 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. 38 C.F.R. § 3.303 (b). Under 38 C.F.R. § 3.303 (b), an alternative method of establishing an in-service disease or injury and a nexus for chronic diseases is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage v. Gober, 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). 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, 10 Vet. App. at 495-96; see Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303 (b). Where 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 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). 1. Entitlement to service connection for right hip disorder. 2. Entitlement to service connection for left hip disorder. The Veteran's service treatment records (STRs) show in October 1969 "RA commission" examination, the examiner found normal lower extremities. Additionally, the Veteran denied past or current arthritis, rheumatism or bursitis, bone joint or other deformity or lameness. Although admitting a past or current history of broken bones, the treatment provider noted these to be childhood injuries of a broken right wrist and right second finger. A December 1970 extended active duty examination shows normal lower extremities. The Veteran also denied past or current arthritis, rheumatism or bursitis, bone joint or other deformity or lameness. The Veteran's broken bone injuries were reported and noted as above. A March 1975 annual examination shows normal lower extremities. An April 1978 treatment notes shows the Veteran complained of pain in the back of his right knee up to his buttock, indicating a possible pulled "hamstring" tendon; however, the Veteran's report indicated the injury most prominently affected his right knee. By May 1978, the Board developed medial-aspect right-leg pain after an earlier "twisting" injury, suggesting a groin-muscle pull. There were otherwise no signs of a back-muscle ache or lumbar injury. In June 1978, the Veteran reported for sick call with back problems. After examination, the treatment provider's impression was "[m]usculoskeletal pain - hip and hamstrings." He recommended hamstring stretches. In a January 1979 periodic examination, the treatment provider found the Veteran's lower extremities to be normal, but noting a left-knee chondromalacia. In this examination, the Veteran denied any past or current history of broken bones, as well as no past or current arthritis, rheumatism or bursitis, bone joint or other deformity or lameness. A November 1979 treatment note shows the Veteran's complaints of low-back pain. The treatment provider found on examination pain to palpation at the right sacroiliac joint and assessed the Veteran with mechanical low-back pain. In December 1979, the Veteran presented again with ongoing pain in both hips, as well as low-back pain. The treatment provider noted he had been prescribed exercises for his back in November 1979, with only some temporary relief. On examination, he found no numbness, muscle strength and size was normal and deep tendon reflexes were within normal limits. He too assessed the Veteran with mechanical low-back pain. In an April 1983 periodic examination, the examiner found the Veteran's lower extremities to be normal and the Veteran reported his health as "[e]xcellent." Additionally, the Veteran denied past or current arthritis, rheumatism or bursitis, bone joint or other deformity or lameness. The treatment provider identified the Veteran's childhood broken bones of a broken right "forearm" and right second finger. In an April 1988 "over 40" examination, the examiner found lower-extremity abnormalities, but noted "moderate swelling R ankle," related to his medical history of right-ankle sprain with persistent pain for 1 year. In March 1988, the Veteran presented at sick call with having "pulled something" in his middle back, he reported this had happened in the past, but he never sought treatment. The treatment provider assessed muscle strain and spur. A May 1991 treatment note shows the Veteran's complaint of right-heel pain for 1 week and the treatment provider's assessment of heel spur. In June and July 1991, the Veteran presented with right-ankle stiffness and was assessed with degenerative joint disease, with a treatment plan addressing only his ankle and a finger. The Veteran also complained of lumbar-spine pain, radiating to the left leg. The treatment provider assessed the Veteran with lumbosacral strain and prescribed physical therapy for back exercises. In the Veteran's 1992 separation examination, the examiner found his lower extremities to be normal. In his statement of his present health, the Veteran's stated he was in good health, "except for occas[]ional periods of benign vertigo and foot + ankle soreness." As in nearly all his in-service examinations, the Veteran admitted to past broken bones and the examiner noted his childhood injuries. Additionally, the Veteran reported past or current foot trouble, the examiner set forth detailed hand-written notes about the Veteran's foot and ankle disorders, but otherwise the Veteran denied past or current arthritis, rheumatism or bursitis, bone joint or other deformity or lameness. A post-service private orthopedic record from July 2012 notes the Veteran's reports of left hip restricted range of motion, pain and limping when walking. The treatment provider assessed the Veteran with severe left hip osteoarthritis and agreed that left total hip replacement surgery was necessary. In a January 2013 visit for private treatment at the Scottsdale Joint Center, the Veteran reported pain and stiffness with left hip range of motion, during which pain is elicited into the groin with flexion and internal rotation, with bone-on-bone grinding. X-rays revealed joint space narrowing, grinding and subchondral sclerosis. The treatment provider diagnosed left hip osteoarthritis. In March 2013, the Veteran's treatment provider noted the Veteran's history of left hip osteoarthritis, with severe pain on flexion and internal rotation, and proceeded with a left total hip replacement. In November 2014, the Veteran underwent a right total hip replacement. His treatment provider noted the Veteran's history of end-stage right hip arthritis. The Veteran's preoperative diagnosis was right hip pain, osteoarthritis and protrusion abnormality, with chronic pain and impingement and leg-length inequality. In January 2017, the Veteran was afforded a VA examination for hip and thigh conditions, in which the examiner confirmed November 2014 and March 2013 diagnoses of right and left total hip replacements (initially, she mistakenly reversed the years and months in her diagnosis and they appear correctly later in the examination). She additionally diagnosed residual pain status post bilateral hip replacement. After extensive testing during examination, the examiner noted that, although imaging studies were available, they did not document degenerative or traumatic arthritis. She opined that the Veteran's diagnosis of a bilateral hip condition is less likely than not (less than 50 percent probability) incurred in or caused by parachute jumps, ranger school and other military physical training in 22 years of service. She explained in her rationale that the claims file showed no records of chronicity of care for hip discomfort until the Veteran's 2013 and 2014 surgeries. Furthermore, there are no files of chronicity of care in 2015 or 2016, thereby showing no indication of a relation to military service. However, the Agency of Original Jurisdiction subsequently asked the January 2017 VA examiner to provide an addendum to her opinion and consider any other potentially relevant evidence in the file and restate her rationale accordingly. In April 2018, a second examiner confirmed the previous opinion, explaining in her rationale that, after reporting during active service bilateral hip pain in December 1979 and a right-groin pull in April 1978, there are no complaints of chronic hip pain for the next 13 years of service, to include no mention of such symptoms by the Veteran on the March 1992 separation exam. Moreover, the January 2013 private treatment notes indicate the onset of left hip pain to be 3 to 4 years prior, which would make the onset of a chronic hip disorder to be around 2009. She added that August 2011 x-rays revealed severe left hip osteoarthritis and moderately severe right hip osteoarthritis. The examiner concluded that, without evidence of chronic and continuous hip conditions since the in-service December 1979 complaint, the medical evidence of record does not show the onset of arthritis, resulting in hip replacements and, therefore, a nexus has not been established. The Board has carefully considered the Veteran's contentions in a July 2016 Statement in Support of Claim, the statement accompanying his January 2017 Notice of Disagreement, a statement accompanying his June 2017 substantive appeal, and the May 2018 lay statement of Lieutenant Colonel R.E.B. (retired), as well as the Veteran's reports to treatment providers and examiners as they appear throughout the record. The Board is well aware that lay persons are competent to report on matters observed or within their personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Therefore, the Veteran and R.E.B. are competent to provide statements of symptoms which are observable to their senses and ordinarily there would be no reason to doubt their credibility. Nonetheless, their lay evidence in turn must be weighed against other evidence, as all relevant evidence of varying kinds must be considered. The Veteran's statements and reports essentially contend that his hip disorders are caused by active-duty physical trauma associated with parachute training and over 20 jumps from aircraft during his career as an Army Ranger, as part of special operations forces, but for which he did not seek treatment, due to concern for more serious disorders and because seeking treatment, unless absolutely necessary, would have been perceived by others in a negative light. Yet, the Veteran also asserts that injury to his hips was not diagnosed accurately during active service. The Board understands the Veteran's reasoning in his statements and reports, but, in looking to his contention that his hip injuries were severe in service, with ongoing pain after service and at present pronounced, unabated pain associated with the injuries, the Board cannot readily reconcile this current characterization of hip injuries with the STRs, which show a June 1978 complaint by the Veteran, noted by the treatment provider as "problems [with] back," but which, after examination, the treatment provider identified in his diagnostic impression as "[m]usculoskeletal pain - hip and hamstrings" and for which he recommended hamstring stretches. A second reference by the Veteran to hip pain in December 1979, but which was in connection with low-back pain appearing a month earlier. In both June 1978 and December 1979, the Veteran's complaints and the treatment provider's findings in fact indicate primary preoccupations with other injuries. Moreover, that hip injuries might not be accurately diagnosed would be, at least in some significant measure, dependent on the Veteran's own reporting to his treatment providers. In short, if a patient does not verbally articulate what body-segment is affected or at the very least point with his finger to the relevant part of his person, there is no reason why a medical professional would accordingly assign a diagnosis elsewhere. The STRs do not show such reports by the Veteran. In this respect then, the Veteran's lack of emphasis in directing the attention of his treatment providers to the situs of his pain and injuries in fact supports his contention that his concerns were with other injuries. Indeed, the in-service medical evidence shows the most prominent orthopedic preoccupations were with persistent symptoms of pain associated with an ankle injury, as well as low back, knee and finger injuries. Hip injuries appear not to have warranted as much attention. Additionally, accepting the Veteran's contention that he avoided seeking treatment for hip injuries to avoid negative perceptions, it seems implausible to the Board that, at the very end of a long and successful active-duty career, the Veteran would not have reported his claimed severe hip disorders as past or current injuries in the March 1992 final separation examination. For these reasons, although competent to report his symptoms, the Board finds the Veteran's assertions of the significance, prominence and intensity of his hip injuries in the period of active service, as well as his reasoning in providing an explanation for the lack of attention he drew those injuries, not to be credible. See Buchanan v. Nicholson, 451 F 3d 1331 (Fed Cir. 2006). R.E.B. describes in his May 2018 lay statement how an injury leading to medical treatment and to a physical profile would, in effect, be a detriment to an officer's career. He adds that the Veteran in later contact with R.E.B. mentioned his hip disorders and after separation from active service told him how "his incapacity had progressed in time and it affected his ability to walk, work and was an impairment to his social life." Although the Board finds R.E.B. both competent and credible as to what he personally observed and what the Veteran told him, the substance of R.E.B.'s statement does not support a causal connection of the current hip disorders to events or injuries during active service. In what he told R.E.B., the Veteran has drawn his own conclusions, but without medical findings of injuries severe enough to remain identifiable, ongoing and disabling from the June 1978 and December 1979 complaints of hip pain through to the end of active service in March 1992, the Veteran's conclusions are not credible as a basis of causation of the current disorders. As stated, the Veteran links his hip disorders to active service. Yet, the April 2018 examiner observed there were no complaints of chronic hip pain for the 13 years of service following December 1979, there was no mention of such symptoms by the Veteran on the March 1992 separation examination and, based on the Veteran's own reports, the onset of hip pain started around 2009. As a factual determination by the Board, the severity of the disorders as described by the Veteran would have been otherwise evident in the approximately 17 years between final separation from active service in 1992 and the Veteran's reported manifestation of the disorders sometime in 2009. Overall, the Board assigns greater probative weight to the opinion of the April 2018 VA examiner, as she is a medical professional who thoroughly reviewed the Veteran's medical history and, for the reasons discussed above, her opinion therefore is adequate for VA adjudication purposes. See generally Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (noting that the central issue in assessing the adequacy of an opinion is whether the examiner was informed of the relevant facts in rendering a medical opinion). Finally, arthritis, as associated with right and left hip disorders, may be eligible for presumptive service connection as a "chronic disease" under 38 C.F.R. § 3.309 (a). As shown above, the record overall indicates pronounced osteoarthritis in both hips. However, the STRs show no reports, treatment or diagnoses of arthritis, as associated with any hip disorder, during active service and the record gives no indication of the manifestation of arthritis within a year of separation from active service. Looking to the possibility of continuity of symptomatology establishing a nexus between any in-service event, injury or illness, to include right and left hip disorders, and arthritis as a subsequent chronic disease, the Board notes that, putting aside the lack of medical evidence of any treatment for arthritis at that time, it is otherwise impossible to establish continuity of symptomatology by relating the Veteran's current arthritis to active-service training, particularly the effects of parachute training, jump exercises and subsequent missions, after the approximately 17 years since discharge from active service before the earliest appearance of arthritis, which the Veteran himself reported as being around 2009, according to the January 2017 VA examiner. Consequently, the presumption of service connection for arthritis as a chronic disease, associated with right and left hip disorders, is not available to the Veteran. As shown by the summary of the record above, there is no evidentiary basis on which to establish a causal relationship between the current right and left hip disorders and an injury or event during active service. In short, hip pain, noted twice in service, was not severe enough to impel the Veteran to seek treatment during active service, nor did he directly after active service or in the years following active service, until actual medical evidence of treatment for left hip pain appears in the record in July 2012. As such, the medical evidence of record cannot establish a "nexus" between the current disabilities and an event or injury during active service. For the foregoing reasons and based on the objective medical evidence, the Board finds the preponderance of the evidence is against the claim for service connection for right and left hip disorders on any basis. In making its determination, the Board has considered the benefit of the doubt doctrine; however, as the preponderance of the evidence is against the claims, that doctrine is not applicable. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3; Gilbert, supra. The claims are denied. JEREMY J. OLSEN Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. Franke, 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.