Citation Nr: 21014402 Decision Date: 03/12/21 Archive Date: 03/12/21 DOCKET NO. 12-13 928 DATE: March 12, 2021 ORDER Service connection for a left hip disorder is denied. Service connection for a left leg disorder is denied. FINDINGS OF FACT 1. The Veteran had active duty from January 1968 to February 1971; he has been 100 percent disabled since May 2009 based on unemployability. 2. A left hip disorder, diagnosed as osteoarthritis and status/post total joint arthroplasty, and a left leg disorder, diagnosed as osteoarthritis and patellofemoral pain syndrome, were not shown in service, symptoms were not continuous since service, and were not shown to a compensable degree within one year of service; left hip and left leg disorders are not causally or etiologically related to service and were not caused by or permanently worsened in severity by a service-connected disability. CONCLUSIONS OF LAW 1. A left hip disorder was not shown in service, is not proximately due to, aggravated by, or the result of a service-connected disability, and is not presumed to have been or shown to have been incurred in service. 38 U.S.C. §§ 1110, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309, 3.310 (2020). 2. A left leg disorder was not shown in service, is not proximately due to, aggravated by, or result of a service-connected disability, and is not presumed to have been or shown to have been incurred in service. 38 U.S.C. §§ 1110, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309, 3.310 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In January 2019, the Board denied the issues on appeal. The Veteran appealed to the Veterans Claims Court. In November 2019, Court Clerk granted a Joint Motion for Remand (JMR). In September 2020, the Board remanded the issues for further development. The RO substantially complied with the prior Board decision’s remand instructions. Stegall v. West, 11 Vet. App. 268 (1998). Turning to the relevant laws and regulations, service connection may be granted on a direct basis as a result of disease or injury incurred in service based on nexus using a three-element test: (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 by service. See 38 C.F.R. §§ 3.303(a), (d); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). Service connection may be granted on a secondary basis for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury under 38 C.F.R. § 3.310. Allen v. Brown, 7 Vet. App. 439 (1995). In order to establish service connection on a secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a link between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Service connection may be granted on a presumptive basis for diseases listed in 38 C.F.R. § 3.309 under the following circumstances: (1) where a chronic disease or injury is shown in service and subsequent manifestations of the same disease or injury are shown at a later date unless clearly attributable to an intercurrent cause; or (2) where there is continuity of symptomatology since service; or (3) by showing that the disorder manifested itself to a degree of 10 percent or more within one year from the date of separation from service. See 38 C.F.R. § 3.307. Left Hip Disorder The Veteran has claimed that a left hip disorder was due to service or, in the alternative, was caused or aggravated by a service-connected disability. Direct, secondary, and presumptive theories of entitlement have been claimed by the Veteran or raised by the record, so each will be analyzed in turn. Turning to the evidence, the first element of service connection – a current disorder – is met, as the Veteran was diagnosed with osteoarthrosis in a May 2009 X-ray. This has also been referred to as osteoarthritis or “OA” in medical records. Moreover, the diagnosis of osteoarthrosis or osteoarthritis has been confirmed by March 2012, March 2018 and October 2020 VA examiners. As such, the first element for all theories of entitlements is met. Next, the second element of service connection on a direct basis – an in-service incurrence – is not met as a review of the service treatment records (STRs) fails to show any complaints of, treatment for, or a diagnosis of any left hip complaints. Additionally, the Veteran has not claimed that any event or injury was incurred in service. As such, the second element is not met, and the medical evidence does not support service connection on a direct basis. Turning to secondary service connection, the first element is met as the Veteran has been diagnosed with left hip arthritis, and the second element – a service-connected disability – is also met as he is service-connected for the excision of a right thigh liposarcoma and right hip arthritis. As such, the first and second elements of secondary service connection are met. As to a medical nexus, a March 2010 VA physical therapy (PT) note reflected “chronic weakness right leg, compensates with left leg. Consequently, left hip and left knee OA.” While this statement suggested an etiological relationship between a left hip disorder and a right thigh disability, it fails to include a rationale. Rather, it is a statement of symptoms absent any explanation of the relationship. As such, it is of lesser probative value. A March 2012 VA examiner found that the Veteran’s left hip disorder was less likely than not caused by or aggravated by his service-connected right thigh liposarcoma because the left hip pain resolved following 2011 left hip arthroplasty. At the time of the examination, the Veteran was not yet service-connected for right hip osteoarthritis, so the opinion has less probative value as to the secondary issue, but still provided a reasoned rationale why the service connected right thigh liposarcoma was not etiologically related to the left hip arthritis. A March 2018 VA medical opinion also found no etiological relationship between a left hip disorder and a service-connected disability; however, the JMR found this examination inadequate. At an October 2020 VA examination, the Veteran reported he had long-standing hip pain that became worse of the years, despite improvement after a total left hip arthroplasty. He remarked that his pain worsened with increased activities and he used a cane. In contract to the PT note, the examiner found it was less likely than not that that a left hip disorder was proximately due to or aggravated by a service-connected disability. The examiner reasoned that the medical literature did not support a causal relationship between osteoarthritis in opposite joints, including the hips. The examiner further found the medical literature also failed to support a causal relationship between liposarcoma and hip osteoarthritis. Instead, he opined that osteoarthritis was caused by a natural progression of aging or by repetitive injury to the respective hip. The examiner concluded that there was insufficient evidence to show a baseline level of severity for left hip osteoarthritis and it was not aggravated for the same reason, that is, osteoarthritis developed due to the natural progression of aging or by repetitive injury to the respective hip. This evidence weighs against the appeal. A review of his VA treatment record and all private medical records associated with the file fails to show that a medical professional, other than the March 2010 PT notation discussed above, has established a nexus between the left hip disorder and the Veteran’s service connected right hip and right thigh disabilities. As such, the third element of service connection is not met, and the medical evidence does not support service connection on a secondary basis. Next, as osteoarthritis is chronic diseases, presumptive service connection under 38 C.F.R. § 3.303 and 3.309 will be considered. To that end, a review of the STRs fails to show a diagnosis of any chronic left hip injury or symptoms during service. Similarly, no evidence shows that a chronic disease developed to a compensable degree in the year following separation from service. Therefore, the medical evidence does not support presumptive service connection of a chronic in service, or compensable within one year of service basis. As to continuity of symptomatology, the Veteran reported to the March 2012 examiner that his left hip pain began in 2004. In May 2009, he related to the clinician that it 2006. Even considering that the symptoms started as early as 2004, this was more than 30 after separation from service. Similarly, a review of available record fails to show continuous symptoms of left hip pain since separation until his diagnosis. As such, the medical evidence does not support service connection on a presumptive basis. Left Leg Disorder The Veteran claims that a left leg disorder was due to service or, in the alternative, was caused or aggravated by a service-connected disability. Direct, secondary, and presumptive theories of entitlement have been claimed by the Veteran or raised by the record, so each will be analyzed in turn. Additionally, although his initial claim was for a left leg disorder, during the appeal period this has expanded to include a left knee disorder. Turning to the evidence, the first element of service connection – a current disorder – is met, as the Veteran was diagnosed with patellofemoral pain syndrome and degenerative arthritis of the left knee based on X-rays taken in conjunction with an October 2020 VA examination. As such, the first element for all theories of entitlement is met. Next, as to direct service connection, the second element – a in-service incurrence – is not met, as the STRs fail to show any diagnosis of, treatment for, or complaints of a left knee or leg disorder. Further, the Veteran has not made any specific complaints of an injury during service as the direct cause of his current disability. As such, the second element is not met, and the medical evidence does not support service connection on a direct basis. Turning to service connection on a secondary basis, the first element is met as the Veteran has been diagnosed with left knee patellofemoral pain syndrome and left knee arthritis, and the second element – a service-connected disability – is also met as he is service-connected for both right thigh liposarcoma and right hip arthritis. As such, first and second elements of secondary service connection are met. As to a medical nexus, as noted above, a March 2010 VA PT note suggested the left leg was compensating for right leg weakness. Further, a March 2009 PT note reflected pain in the left knee was probably from compensating for right leg weakness. The March 2009 statement is neither definitive nor supported by a reasoned rationale. Similarly, the March 2010 statement regarding chronic weakness in the right leg, compensating with the left leg, consequently leading to left knee osteoarthritis is without a supporting rationale. Further, other than the Veteran’s own report of history, there had been no diagnosis of left knee osteoarthrosis or osteoarthritis supported by diagnostic testing at that point. February 2010 VA X-rays of the left knee showed no fracture or dislocation, normal mineralization and alignment with no soft tissue abnormality. In contrast, the October 2020 VA examiner gave a detailed and well-reasoned rationale as to why it was less likely than not that a left leg disorder was proximately due to or aggravated by service. The Veteran described his long-standing left knee pain as worsening over time, and that it hurt primarily with prolonged standing or walking, especially with hills. The examiner reasoned that although the Veteran was noted to have knee pain in 2008, the current diagnosis was found in 2020 X-rays which showed very mild osteoarthritis of the patellofemoral compartment. In addition, 2010 and 2012 X-rays failed to show osteoarthritis of the knee. The examiner continued that the current examination failed to show an altered gait as noted in 2009, and from the Veteran’s history, it was apparent many of his left leg symptoms initially resolved following the left total hip arthroplasty. Further, the examiner noted that patellofemoral pain syndrome was caused by repetitive injury to the knee or by a single high velocity injury causing imbalance between the medial lateral compartments, and that osteoarthritis of the left knee was a natural progression of aging. The examiner used similar reasoning in finding that it was less likely that the left knee disorders were aggravated by service-connected disabilities, stating again that patellofemoral pain syndrome was instead caused by repetitive injury to the knee or by a single high velocity injury causing imbalance between the medial lateral compartments, and that the osteoarthritis of the left knee was a natural progression of aging. As stated above, the 2019 Court JMR found that a March 2018 VA medical opinion that also found no etiological relationship between any left knee or leg disorder and a service-connected disability to be inadequate. The March 2012 VA examiner did not diagnose the Veteran with a left knee or leg disorder, stating that the pain completely resolved after the 2011 left hip total joint arthroplasty. The examiner further that ipsilateral left knee pain was due to some common innervation, and as the pain resolved after surgery, it was due to left hip issues rather than his service-connected right thigh excised liposarcoma. At the time, the Veteran was not yet service connected for right hip arthritis, so this opinion has less probative value than the October 2020 opinion. A review of VA and available private medical records fail to show any positive nexus opinions linking a left leg or knee disability to any service-connected disability. The October 2020 opinion is particularly probative as it provides a well-reasoned rationale, engages with the evidence of record and provides an alternative etiology for his current disabilities. As such, the third element is not met, and service connection on a secondary basis is not warranted by the evidence. Next, as above, osteoarthritis is a chronic disease and as such service connection on a presumptive basis as described in 38 C.F.R. § 3.303 and 3.309 will be considered. To that end, the STRs and other available records fail to show a diagnosis with any chronic left leg or knee disease during service. Similarly, the evidence does not show a chronic left leg or hip disorder manifesting to a compensable level in the year following separation from service. Therefore, the medical evidence does not support presumptive service connection of a chronic in service or compensable within one year of service basis. As for continuity of symptomatology, December 2009 VA medical records show that the Veteran reported chronic knee pain since 1992; however, the March 2012 VA examiner found that the pain was significantly reduced following the 2011 left total hip arthroplasty. Even considering symptoms as early as 1991, this was 20 years after discharge. Further, arthritis was specifically not confirmed by X-ray until October 2020, nearly 50 years after discharge. As such, the medical evidence does not support service connection on a presumptive basis. The Board has considered the Veteran’s lay statements that that his disorders were caused by service. He is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. However, he is not competent to offer an opinion as to the etiology of his current disorders due to the medical complexity of the matters involved. Specifically, in a February 2021 brief, the Veteran argued that the March 2010 PT suggesting that an altered gait could have affected his left hip, and that the VA examinations of record were inadequate for not addressing this; however, the October 2018 examination specifically addressed his gait, which was not altered at the time of the examination. Moreover, the Board finds that the examinations were adequate for evaluation purposes. Specifically, the examiners reviewed the claims file, interviewed the Veteran, and conducted physical examinations. There is no indication that the VA examiners were not fully aware of the Veteran’s past medical history or that they misstated any relevant fact. Moreover, the examiners have the requisite medical expertise to render medical opinions regarding the etiology of the hip and leg/knee disorders and had sufficient facts and data on which to base the conclusions. Further, there is no contradicting medical evidence of record. Therefore, the Board finds the VA examiners’ opinion to be of great probative value. In addition, the RO has attempted to obtain private medical records by providing the Veteran with authorization for release on multiple occasions; however, he has not returned these forms and thus the RO was unable to obtain all of his reference private medical records. The RO made reasonable efforts to obtain these records, and thus further remand for development is unwarranted. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) In sum, the Veteran and his representatives are not competent to make an etiological connection, and such competent evidence has been provided by the service records, clinical evidence, and examinations obtained and associated with the claims file. Here, the Board attaches greater probative weight to the clinical findings than to his statements. In light of the above, the preponderance of the evidence is against the claims for service connection and there is no doubt to be otherwise resolved. As such, the appeals are denied. Finally, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, for the Board’s consideration. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). L. HOWELL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Brendan A. Evans, 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.