Citation Nr: 21013542 Decision Date: 03/09/21 Archive Date: 03/09/21 DOCKET NO. 11-05 362 DATE: March 9, 2021 ORDER Entitlement to service connection for left hip disability, to include as due to a service-connected left knee or lumbar spine disability, is denied. FINDING OF FACT The Veteran’s left hip disability not secondary to his service-connected left knee and lumbar spine disabilities, and is not otherwise related to an in-service injury or disease. CONCLUSION OF LAW The criteria for service connection for a left hip disability due to service or service-connected disease or injury are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from August 1981 to August 1985. T The Board previously remanded the claim in February 2017. In May 2018, the Board denied the Veteran’s claim, finding that the Veteran’s left hip disability was not aggravated or caused by his service-connected lumbar spine or left knee disabilities. The Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (Court). In a September 2019 Joint Motion for Remand (JMR), the Court vacated the May 2018 Board decision and remanded the claim to the Board. Following remand by the Court, the Board remanded the claim in December 2019 for an addendum medical opinion. The Board again remanded this matter in September 2020 to obtain updated VA treatment records and a VA medical opinion. As the updated VA treatment records and addendum opinion have been obtained, there has been substantial compliance with the prior remand directives and the matter is again before the Board. See Stegall v. West, 11 Vet. App. 268 (1998). Entitlement to service connection for left hip disability, to include as due to a service-connected disability The Veteran contends that he incurred a left hip disability during active service. He alternatively contends that either his service-connected lumbar herniated nucleus pulposus, status-post laminectomy with scar, or service-connected left knee patellofemoral pain syndrome caused or aggravated his current left hip disability. Legal Criteria Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may be established for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that disease was incurred in service. 38 C.F.R. § 3.303(d). Generally, to prevail on a claim of service connection on the merits, there must be competent evidence of (1) current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence or other competent evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. See Hickson v. West, 12 Vet. App. 247 (1999); Jandreau v. Nicholson, 492 F.3d at 1372. Service connection may be granted on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. The evidence must show: (1) that a current disability exists; and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated (permanently worsened in severity beyond its natural progress) by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448-49 (1995). In some cases, a grant of service connection is available on a presumptive basis. Service connection may be presumed for certain chronic conditions, such as arthritis, if a veteran served continuously for 90 days or more during a period of war or during peacetime after December 31, 1946, and the condition manifested to a compensable degree within one year of the date of discharge from service. 38 C.F.R. §§ 3.307, 3.309. Medical and Lay Evidence During service, the available service treatment records (STRs) do not show treatment or complaints of a left hip condition. At the August 1981 enlistment physical examination, the Veteran denied all relevant pre-service medical history and clinical evaluation was completely normal. The Veteran was involved in a truck accident in November 1982 which resulted in ongoing complaints of and outpatient treatment for a variety of low back problems following this in-service accident. He reported back problems related to his November 1982 truck accident at a periodic physical examination in March 1984. Clinical evaluation was completely normal. At his separation physical examination in June 1985, clinical evaluation of the Veteran was completely normal, and no relevant in-service medical history was reported. After service, VA outpatient treatment records show ongoing complaints of and treatment for left hip pain and arthralgia. At a May 2016 VA hip and thigh examination, the Veteran’s complaints included flare-ups of left hip pain which occasionally caused him to limp while walking. The Veteran had difficulty with prolonged standing or walking. The VA examiner reviewed the Veteran’s claims file, including his service treatment records and post-service VA treatment records. Physical examination of the left hip showed an abnormal range of motion, difficulty with squatting, pain on extension and internal rotation, no additional limitation of motion following repetitive testing, less movement than normal, normal muscle strength throughout, and no ankylosis. The VA examiner opined that it was less likely than not that the Veteran’s service-connected lumbosacral spine disability caused or aggravated his left hip disability. The rationale for this opinion was that, although the Veteran had a history of chronic lumbar disability, “this in and of itself does not necessarily lead to problems with the hip.” The diagnosis was trochanteric pain syndrome of the left hip. In a February 2018 opinion, a different VA clinician opined that it was less likely than not that the Veteran’s current left hip disability was related to active service, including as due to a service-connected left knee disability. The rationale for this opinion was that the Veteran’s mild left hip degenerative changes diagnosed in 2009 by x-ray were “consistent with natural aging regardless of career choice.” The rationale also was that mild left hip degeneration was “clinically expected for [the Veteran’s] age and occupation [and was] not aggravated beyond what is clinically expected due to [the] natural progression of the condition.” The rationale also was that left knee pain would be expected to reduce and not increase the load bearing on the left lower extremity (hip) and a review of x-ray imaging did not show any anatomic anomaly to suggest unusual wear and tear. Pursuant to the September 2019 JMR, an addendum opinion was obtained in January 2020. The January 2020 VA examiner agreed with the prior VA examiners’ negative nexus opinions regarding the Veteran’s left hip disability. In her rationale, the VA examiner stated that “the Veteran was overweight for many years prior to [diagnosis] of [osteoarthritis (OA)] of the hip…. This places an additional stress on the subject ot wear and tear over time.” She further noted that the Veteran was overweight during this period, though the examiner did not say the Veteran was obese. The examiner also noted the Veran had other additional risk factors and other diseases and stated that “weight must be considered in the development of OA.” The January 2020 VA examiner also provided another addendum opinion in February 2020. The examiner opined that the Veteran’s left hip disability was not caused or aggravated by the Veteran’s service-connected left knee and lumbar disabilities. She reasoned that imaging studies “fail[ed] to show anatomical misalignment between hips, knees, and back.” The examiner stated that the Veteran was overweight and that “[i]ncreased weight puts added stress on weight-bearing joints, such as [] hips and knees.” She concluded her report by opining that the Veteran’s left hip disability is most likely related to “genetics, age, and obesity which are also risk factors for worsening the underlying hip condition.” The Board notes that the VA examiner stated in February 2020 that there was no anatomical misalignment between hips, knees, and back. In September 2020, the Board again remanded this matter for additional consideration of aggravation, compliant with the holding of Ward v. Wilkie, which held that service connection is warranted for any incremental increase in disability or any additional impairment of earning capacity in non-service-connected disability resulting from service-connected conditions regardless of its permanence. See Ward v. Wilkie, 31 Vet. App. 233 (2019). The Board also directed the VA examiner to consider Walsh v. Wilkie, which held that that obesity as an intermediate step in a causal chain for service connection can be established on either a causal or aggravation basis. See Walsh v. Wilkie, 32 Vet. App. 300, 306-307 (2020) In December 2020, the requested VA addendum opinion was provided. After reviewing the Veteran’s medical history and examining the Veteran, the December 2020 examiner concluded that the Veteran’s left hip condition was less likely than not the result of his service-connected conditions. The examiner reasoned that degenerative arthritis is more common with advanced aging unless there is a history of significant injury or trauma to the joint. The Veteran’s arthritis would have at least as likely as not occurred, regardless of weight gain, due to advancing age. The Veteran’s age at diagnosis was 49. The overall prevalence of osteoarthritis rises from 1% in people under 30 years to almost 10% in those over 40 years, and 50% in those over 60 years. The examiner cited medical literature to support this conclusion. In an additional addendum opinion, the December 2020 examiner again opined that that the Veteran’s left hip condition was less likely than not the result of his service-connected conditions. The examiner explained that arthritis in one joint does not cause arthritis in another joint. The examiner explained that a thorough review of medical literature failed to show such causal relationship. It is not unusual for two joints to share properties in the same person, but one joint’s disease does not spread to another or cause damage to it. Therefore, the examiner concluded that the degenerative arthritis of the left hip is less likely than not related to the degenerative arthritis lumbar spine, status/post laminectomy. As to aggravation, the December 2020 examiner found that the Veteran’s left hip condition was less likely than not aggravated beyond its natural progression by his service-connected conditions. The examiner found no objective evidence of major muscle or damage resulting in complete paralysis or shortening of the injured limb to alter the gait pattern to a clinically obvious Trendelenburg gait. This level of severity was not supported based on records review, history, or examination. Therefore, the examiner concluded that it is less likely than not the Veteran’s left hip arthritis was aggravated beyond its natural progression by the left knee patellofemoral pain syndrome or lumbar spine disability. Pursuant to the September 2020 JMR, the December 2020 examiner considered obesity as an intermediate step in a causal chain for service connection can be established on either a causal or aggravation basis. See Walsh v. Wilkie, 32 Vet. App. 300, 306-307 (2020). On examination, the Veteran appeared well nourished but not obese. Although the examiner did not have a scale in the office, the examiner accepted the Veteran’s stated height and weight, to determine the Veteran’s Body Mass Index (BMI). BMI is a measure of body fat based on height and weight. The examiner noted that obesity is defined as BMI of 30 or more. The examiner found that the Veteran’s stated height and weight on the day of the examination indicate a BMI of 25, which did not constitute obesity. The examiner found that this BMI was consistent with his trend from available documentation. The examiner listed BMI recordings in the Veteran’s medical history from 2009 to 2018, which were all under 30. Analysis The Board finds that the opinions of the December 2020 VA examiner are the most probative evidence of record as to whether the Veteran’s current left hip disability is related to service or a service-connected condition. The opinions were based on a thorough review of the Veteran’s medical records, consideration of his lay assertions, and supported by a fully articulated rationale with citations to medical literature. Prejean v. West, 13 Vet. App. 444 (2000); Guerrieri v. Brown, 4 Vet. App. 467 (1993). The Board further notes that the findings of the December 2020 VA examiner are consistent with the findings of the May 2016 and February 2018 VA examiners. There are no private or VA medical opinions which contradict these findings. The Board acknowledges the Veteran’s contention that his left hip disability is related to service or a service-connected disability. The Veteran is competent to provide testimony concerning factual matters of which he has first-hand knowledge (i.e., experiencing symptoms either in service or after service). See, e.g., Barr v. Nicholson, 21 Vet. App. 303 (2007); Washington v. Nicholson, 19 Vet. App. 362 (2005). However, as a layperson without the appropriate medical training and expertise, the Veteran is simply not competent to provide a probative opinion on a complex medical matter, such as an etiological relationship between any current disability and an injury in military service. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board has also considered whether a grant of service connection is available on a presumptive basis. Here, the Veteran is competent to report hip pain symptoms since service. However, there is no medical evidence that the Veteran was treated for any hip disability within a year of his discharge from service. In sum, the competent evidence of record weighs against the Veteran’s assertion that his hip disability is related to his active service or his service-connected lumbar spine and left knee disabilities. A preponderance of the medical evidence of record does not show manifestations of a left hip disability during service or within one year of service. The medical opinions of record find that the Veteran’s hip disability was not related to service or a service-connected disability. The December 2020 VA examiner cited medical literature in finding that arthritis does not spread from one joint to another. The December 2020 VA examination found no objective evidence of major muscle or damage resulting in complete paralysis or shortening of the injured limb to alter the gait pattern, which led the examiner to conclude that the Veteran’s service-connected conditions did not cause or aggravate his left hip disability. The December 2020 VA examiner also reviewed the Veteran’s medical history and found that the Veteran did not meet the clinical definition of obesity during the period on appeal, precluding obesity as an intermediate step for causation or aggravation. Therefore, a preponderance of the medical evidence of record supports a conclusion that the Veteran’s service-connected lumbar spine and left knee disabilities did not cause or aggravate, permanently or non-permanently, his left hip disability. Although grateful for the Veteran’s honorable service, the Board concludes that the preponderance of the evidence is against the claim for service connection, and the benefit of the doubt rule does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). JENNIFER HWA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Casey, 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.