Citation Nr: 21011542 Decision Date: 03/02/21 Archive Date: 03/02/21 DOCKET NO. 15-23 207 DATE: March 2, 2021 ORDER Entitlement to service connection for a left knee disability secondary to the service-connected right knee disability is denied. Entitlement to service connection for a right hip disability secondary to the service-connected right knee disability is denied. Entitlement to service connection for a left hip disability secondary to the service-connected right knee disability is denied. FINDINGS OF FACT 1. The Veteran’s left knee disability was not present in service nor did it manifest to a compensable degree within one year of service discharge and is not otherwise related to service or a service-connected disability. 2. The Veteran’s right hip disability was not present in service nor did it manifest to a compensable degree within one year of service discharge and is not otherwise related to service or a service-connected disability. 3. The Veteran’s left hip disability was not present in service nor did it manifest to a compensable degree within one year of service discharge and is not otherwise related to service or a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for a left knee disability secondary to the service-connected right knee disability have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 2. The criteria for service connection for a right hip disability secondary to the service-connected right knee disability have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 3. The criteria for service connection for a left hip disability secondary to the service-connected right knee disability have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1966 to February 1970. These matters are before the Board of Veterans’ Appeals (Board) on appeal from a July 2013 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In August 2018, the Board remanded the issue of service connection for left knee and bilateral hip disabilities for further development. Specifically, to obtain addendum opinions regarding secondary service connection by the service-connected right knee disability. The Board finds that the August 2020 VA addendum opinion complies with the remand instructions and thus the issues are properly before the Board for adjudication. See Stegall v. West, 11 Vet. App. 268 (1998). Service Connection 1. Entitlement to service connection for a left knee disability secondary to the service-connected right knee disability 2. Entitlement to service connection for a right hip disability secondary to the service-connected right knee disability 3. Entitlement to service connection for a left hip disability secondary to the service-connected right knee disability 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; 38 C.F.R. § 3.303 (a). To establish a right to compensation for a present disability, a Veteran 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 - the so-called “nexus” requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). 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. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307 (a)(3), 3.309(a). Continuity of symptomatology may also provide a basis for a grant of service connection for those diseases defined as “chronic” by VA. 38 C.F.R. § 3.303 (b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be established on a secondary basis for a disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439, 446 (1995) (en banc). In order to establish service connection for a claimed secondary disorder, there must be medical evidence of a current disability; evidence of a service-connected disability; and medical evidence of a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-7 (1995). Service connection may be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, any reasonable doubt is resolved in favor of the Veteran. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. The Veteran asserts that his right knee disability causes him to walk and bend differently, which puts unusual strain on his left knee and both hips. The Veteran also contends that his right hip was in pain while at the NCO Academy and was seen at the Maxwell Air Force Base (AFB) in 2004. He specifically alleged that the pain started about two weeks after running on the asphalt. The Veteran also asserts that his left hip disability is caused by his right hip disability, as a result of overcompensation. While the Veteran appears to have limited his argument to principles of secondary service connection for the left knee disability and the left hip disability, direct service connection was also considered by the RO during the course of this appeal. Because there is similar medical history and evidence related to these claims, as well as similar dispositions of the issues, the Board will address them together. In the May 2008 VA knee examination, the Veteran reported that he has moderate low back pain and that it radiates into the right hip. He furthered that both knees are painful, mostly on the right. Both knees have had some occasional collapsing and instability at each knee is mostly a feeling of wobble and it’s worse on the right. The Veteran further reported that the right knee has had two arthroscopic surgeries. Upon examination, the examiner reported that the Veteran’s right knee is painful, but the left knee is not. He furthered that there was mild patellar pain and crepitus with the left knee. In a January 2012 private treatment record, the examiner noted that the Veteran’s left knee has full range of motion (ROM), nontender to palpation, and normal skin. In April 2012, the Veteran complained of right hip pain for about a week that was focal to the trochanteric bursa. In May 2012, the Veteran continued his complaint about his right hip. X-rays showed moderate arthritis of both hips, more notably on the left side with a misshapen femoral head, but had spurs on both hips. The examiner diagnosed the Veteran with trochanteric bursitis. The Veteran was afforded a VA hip examination in October 2012 where the Veteran was diagnosed with bilateral hip chronic strain and bilateral bursitis. The Veteran reported that he developed pain in both his hips in 2004 while he was running on asphalt at USAF NCO Academy. The Veteran reported that he did not go to sick call, which is why it is not reflected in service treatment records (STRs). The Veteran furthered that there was no specific history of trauma or hip surgery. He also reported that the pain is worse in his right hip. According to imaging, the Veteran’s right hip came out normal and his left hip had mild arthritis. The examiner noted that there were scattered areas of heterotopic ossification consistent with bursitis. The examiner opined that there is no anatomical connection between the two hips—one hip does not cause problems with the other hip. The examiner furthered that some systemic disease like degenerative arthritis will affect both hips, but in this instance, the problem with the left hip was not caused by the problems of the right hip. The examiner furthered that the left hip problems were not aggravated beyond natural progression by the right hip problems since there is no anatomical relationship or connection. The Veteran was also afforded a VA knee examination in October 2012 where he was diagnosed with degenerative arthritis in the left knee. The Veteran reported that he developed pain in his left knee in 2011 and that there is no specific history of trauma or surgery regarding it. He reported that the pain is intermittent and located over the patella. X-ray imaging reported that the left knee appeared normal. The examiner opined that it was less likely than not that the Veteran’s right knee disability caused the left knee disability since the Veteran’s left knee problems started prior to his total knee replacement. In a June 2013 VA addendum opinion, the examiner opined that the Veteran’s left hip disability was not due to or aggravated by the Veteran’s service-connected right knee disability. The examiner explained that the Veteran’s left hip disability has the same diagnosis as with his right hip and thus it is not disproportionate. The examiner furthered that soft tissue diagnoses are generally unrelated to bony processes such as joint degeneration. The examiner continued that “in this case, chronic strain and bursitis conditions are unrelated to the particular types of degenerative hip disease (DJD disproportionate to expected age and/or asymmetric degenerative disease of the left hip) for which service connection might be acknowledged in this situation as secondary to the right knee condition (if longterm gait antalgia due to right knee could be demonstrated as contributing an increased workload to left hip)”. The examiner then explained that the Veteran does not have a diagnosis of any degenerative hip disease and his symptoms seem to be symmetric, both of which are against a right knee causation or aggravation mechanism. In the October 2014 VA knee examination, left knee arthritis was shown from imaging. The Veteran submitted records from Maxwell AFB from June 2004 that showed the Veteran had restrictions for physical training. The record reported that the Veteran was unable to run, walk, do push-ups, do sit-ups, or do calisthenics. There was no indication what injury the Veteran was suffering from. In the August 2020 VA addendum opinion, the examiner reported how the Veteran could not be reached to schedule an examination and therefore is providing the opinions. The examiner explained that he reviewed all pertinent evidence of record. The examiner noted that the 2014 VA examination was solely for the Veteran’s service-connected right knee disability even though left knee osteoarthritis was listed in the diagnosis section. The examiner further reported that there was no discussion of the left knee symptoms or examination findings. The examination commented on the Veteran’s statements about right knee giveaways and falls and use of cane, which was determined to not be documented in VA treatment records. The examiner also noted that the VA treatment records do not comment on left knee or bilateral hip issues and if there is some mention, it is cursory. The examiner then explained that the diagnoses then remain as left knee osteoarthritis and bilateral hip chronic strain and bursitis. The examiner furthered that no hip disability is seen in any treatment records and that the diagnosis of chronic strain and bursitis was made by the 2012 examiner based solely on the Veteran’s statements of pain with usage and some limitations in ROM on examination. The examiner continued on to opine that the Veteran’s left knee disability as not at least as likely as note proximately due to his service connected right knee disability since the Veteran’s age of onset of left knee degenerative joint disease is entirely consistent with age related degenerative arthritis. The examiner furthered that the Veteran has moderate obesity which is also a separate risk factor for degenerative joint disease. The examiner furthered that despite the Veteran’s contention of overcompensating for the right knee disability, available care records do not document significant gait antalgia due to the service-connected right knee disability. The examiner explained that there was no documentation of chronic favoring of one leg for the other. The examiner also opined that the Veteran’s left knee disability had not been aggravated by the right knee disability since the Veteran’s left knee disability is still not significant enough even to warrant documentation and discussion by his primary care physician. The examiner moved to opine on the Veteran’s bilateral hip disability. The examiner opined that the Veteran’s bilateral hip disability was not at least as likely as not due to service since there is no evidence of any hip disability or reported hip pain in STRs, nor is there any evidence of any in-service condition or trauma which would be likely to be a later cause of bilateral hip strain and bursitis. The examiner also opined that the Veteran’s bilateral hip disability was not at least as likely as not secondary to his service connected right knee disability since the Veteran himself recalled onset of the hip pain during exercise, which shows that he did not initially believe that the hip issues were related to his right knee issue. The examiner explained that chronic gait effects have never been documented from the service-connected right knee and that there is no evidence that the right knee disability caused any chronic alteration of gait which might then have mechanically affected the hips. The examiner explained that the bilateral hip diagnoses have been symmetrical in nature, which also argues against an antalgic gait effect from the right knee disability. The examiner furthered that the Veteran’s bilateral hip disabilities were not aggravated by the Veteran’s right knee disability since despite that almost eight years have passed since the Veteran initially contended disability from his hips, there is still no documentation in any care record of a requirement for any treatment or any physical limitations of the hips. Based on the foregoing, the Board finds there is no probative and competent medical evidence of record to indicate that the Veteran’s service-connected right knee disability plays any role in the development of his left knee and bilateral hip disabilities. The VA opinion is the most probative and persuasive medical evidence as it is based upon a review of the claims file, sets out the most helpful and complete discussion of the medical questions, and is supported by adequate rationale. In providing the rationale, the VA examiner considered specific medical history including the onset and course of pertinent symptoms, the results of clinical evaluation, and the Veteran’s belief that his left knee and bilateral hip disabilities are related to his service-connected right knee disability. There are no favorable competent opinions of record, and no other medical evidence of record suggests such a relationship. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, musculoskeletal disabilities fall outside the realm of common knowledge of a lay person. In this regard, any actual diagnosis of a left knee or bilateral hip disability requires objective testing to diagnose and can have many causes. See Jandreau, 492 F.3d at 1377, n. 4. To the extent that the Veteran believes that his left knee and bilateral hip disabilities are caused by his right knee disability, as a lay person, he is not shown to possess any specialized training in the medical field. The Veteran’s opinion as to the etiology of his current left knee and bilateral hip disabilities is not competent evidence, as the nexus question involved in this case requires medical expertise to determine. Id. The Board is also unable to attribute the post-service development of the left knee and bilateral hip disabilities to military service. The Veteran did not experience chronic left knee or hip symptoms in service and there is no evidence that either disabilities manifested to a compensable degree within one year of separation from service. 38 C.F.R. §§ 3.303, 3.307, 3.309. There is also no evidence linking the diagnosed left knee and bilateral hip disabilities to service and the Board finds that the criteria to obtain an etiology opinion have not been met because the record does not document complaints or treatment for left knee or hip problems during service or for many years after. Duenas v. Principi, 18 Vet. App. 512, 519 (2004). In this case, any assertion by the Veteran that his left knee and hip disabilities are related to service treads into the realm of medical expertise. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n. 4 (Fed. Cir. 2007). Because the evidence of record does not establish that the claimed left knee and bilateral hip disabilities were present in service, and there is no competent medical evidence relating them to service or a service-connected disability, the claims cannot be granted. 38 C.F.R. §§ 3.303, 3.310; Allen, supra; see also, Wallin, Reiber, supra. Accordingly, the preponderance of the evidence is against the claims and there is no reasonable doubt to be resolved. 38 U.S.C. § 5107 (b). Thomas H. O'Shay Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Imam, 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.