Citation Nr: 21022054 Decision Date: 04/14/21 Archive Date: 04/14/21 DOCKET NO. 15-41 905 DATE: April 14, 2021 ORDER Service connection for left hip trochanteric bursitis, to include as secondary to a service-connected back disability, is denied. FINDING OF FACT There is no probative medical evidence that indicates the Veteran’s current left hip disability was incurred in service, diagnosed within the presumptive period after discharge, or was caused or is being aggravated by his service-connected lumbar spine disability. CONCLUSION OF LAW The criteria to establish service connection for a left hip disability have not been satisfied. 38 U.S.C. §§ 1110, 1131, 5107 (b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310 (2019). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from February 1953 to March 1983. The case was last remanded in December 2019 for evidentiary development and for a new medical examination and opinion. All actions ordered by the remand have been accomplished. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d); see Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Additional disability resulting from the aggravation of a nonservice-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310 (b). See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Certain disorders listed as “chronic” in 38 C.F.R. § 3.309 (a) and 38 C.F.R. § 3.303 (b) are capable of service connection based on a continuity of symptomatology without respect to an established causal nexus to service. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Arthritis and myelitis are “chronic” diseases listed under 38 C.F.R. § 3.309 (a). Therefore, the presumptive service connection provisions based on “chronic” in-service symptoms and “continuous” post-service symptoms under 38 C.F.R. § 3.303 (b) apply. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where the evidence shows a “chronic disease” in service or “continuity of symptoms” after service, the disease shall be presumed to have been incurred in service. 38 C.F.R. § 3.303 (b). Additionally, where a veteran served ninety days or more of active service, and certain chronic diseases, such as arthritis or myelitis, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309 (a). While the disease need not be diagnosed within the presumptive period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. In deciding an appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination about the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994). When considering whether lay evidence is competent, the Board must determine, on a case-by-case basis, whether a veteran’s disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno, 6 Vet. App. 465, 469. Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303 (2007). Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau, 492 F.3d 1372, 1377. In deciding claims, it is the Board’s responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104 (a). When all the evidence is assembled, the Board is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Entitlement to service connection for a left hip bursitis, to include as secondary to a service-connected back disability The Veteran contends that his current left hip disability, diagnosed as left hip trochanteric bursitis, was incurred in service due to the physical strain of being a combat fighter pilot. In a March 2008 statement the Veteran contended that after 30 years of flying jet engines his body was showing the toll of such in-service duties. In a June 2015 statement the Veteran reported that at discharge he had no indications of left hip pain but that he felt since he flew high-performance jet fighters for over 30 years that his current left hip disability was a demonstration of his body’s response to years of high-velocity pressure. Alternatively, the Veteran contends that his service-connected lumbar spine disability caused and/or aggravated his left hip disability. Service treatment records do not indicate any complaints, diagnoses, or treatments for a left hip disability in service. At a June 1983 VA medical examination after discharge, the Veteran reported pain in his left groin/pubic area; pain in his bilateral legs; and low back pain. The examiner noted that the Veteran had low back surgery during service. During his neurological evaluation the Veteran reported being in excellent health until a 1981 transient ischemic attack (TIA). He also reported the history of his 1979 back surgery, which was to address complaints of low back pain that radiated to his lower extremities, more so on his right side than left. He reported the surgery improved his symptoms, although endorsed occasional right foot numbness. He further reported left groin pain, which had been diagnosed as an inflamed nerve in the pubic area. He also reported left leg pain which the examiner noted was more likely varicose vein pain. The examiner diagnosed the Veteran with mild left cerebral vascular accident and right L5-S1 radiculopathy. The orthopedic evaluation revealed that the Veteran’s left hip did not demonstrate heat, redness or swelling; that his left hip’s range of motion was normal; and that his left hip did not demonstrate restriction or pain. Imaging indicated normal hip joints. In April 2002 the Veteran reported bilateral leg pain, with feelings of heat and swelling for about 30 minutes starting one week earlier. He also endorsed six months of leg pain. The physician suspected myositis secondary to the Veteran’s use of Zocor and ordered imaging to confirm whether the incident was related to his muscle or joints. In a followup evaluation, the examiner noted that the Veteran’s bilateral leg pain was not consistent with myositis. Late April 2002 imaging, ordered to rule out osteoarthritis, revealed normal bilateral hips with no evidence of fracture, dislocation, or other abnormality. Private June 2004 treatment records indicate the Veteran fell while ice skating. He reported progressively worsening pain in his pelvic area. Imaging indicated normal sacroiliac and hip joints. An August 2004 initial physical therapy evaluation indicated that the Veteran’s leg pain suggested left lumbosacral radiculopathy. Subsequent findings indicated a tender inguinal (groin) ligament that demonstrated with hip flexion pain. Private July 2006 treatment records indicate the Veteran fell from a ladder. He reported an injury to his right hip and flank area. In a followup consultation, the Veteran reported falling on his right side, then on his left side, with continued pain in his bilateral lower extremities. The examiner noted imaging indicated no evidence of fracture, dislocation, or calcification of the right hip. The examiner assessed the Veteran with a right hip contusion. There were minimal medical findings related to the Veteran’s left hip. Private February 2014 medical records indicate the Veteran reported low back and bilateral hip pain. In November 2014 the Veteran reported left hip pain for the past 3 months, to include occasional sharp burning pain that radiated down his leg; that he had received a diagnosis of trochanteric bursitis; and that he received an injection 6 weeks prior that did not provide relief. An examination revealed tenderness at the spinous processes in the lumbosacral region, and x-ray imaging indicated normal hip alignment with mild degenerative changes at the head of the femur and small osteophyte formation to the greater trochanter. He received another cortisone injection and was advised to return for continued injections every 4-6 months. In a December 2014 follow up consultation, the Veteran reported continued left leg pain, and that the November 2014 injection helped for approximately 1 week. He also reported limping and worsening pain when he stood up from a seated position. An examination revealed painful and limited left hip range of motion, with lateral thigh pain but no groin pain, and with tenderness of the greater left trochanter area. In February 2015 the Veteran reported continued left leg pain, described as pain between his left knee and foot when he is laying down, and that the November 2014 injection into his left hip did not provide relief. An examination revealed painful, limited left hip range of motion, with lateral thigh pain but no groin pain, and with tenderness of the greater left trochanter area. At the June 2015 VA medical examination, the Veteran reported left hip pain that started the previous summer; that the November 2014 injection relief wore off after three to four days; and that his current pain was “very different” from the thigh pain he had during service prior to his low back surgery. The Veteran reported pain when he stood from a seated position. The examiner noted the Veteran’s 2014 diagnosis of left hip bursitis, reviewed the Veteran’s claims file, and conducted a physical evaluation. The examiner opined the Veteran’s current left hip trochanteric bursitis was less likely related to the Veteran’s in-service bilateral thigh pain he reported during service because the Veteran’s current new diagnosis of left hip trochanteric bursitis differed substantially from the Veteran’s reports of thigh pain during service. The examiner further explained that the Veteran’s in-service thigh complaints likely indicated radiculitis related to the Veteran’s lumbar spine stenosis which had improved with the Veteran’s in-service lumbar spine surgery. In a June 2015 statement the Veteran reiterated his belief that his service duties of flying high-performance jet fighters for 30 years was the reason why his body was demonstrating worsening left hip pain. He reported extreme pain when rising from a sedentary position, and difficulty with prolonged walking. At a November 2015 VA medical examination, the examiner noted the Veteran had been diagnosed with trochanteric pain syndrome in his left hip in 2014 and in his right hip in November 2015. The Veteran continued to reiterate his belief that the pain was due to his duties as a pilot during service. The examiner opined that the Veteran’s bilateral hip disability was less likely proximately due to or a residual of the Veteran’s post-operative low back right L5-S1 radiculopathy. The examiner explained that the likelihood of bursitis increased with age, and that repetitive motion was the most common cause of bursitis. At a February 2016 VA medical examination, the Veteran reported chronic localized left hip pain, with newly onset right hip pain. He also reported injections to the left hip did not provide relief; that moving and stretching relieved hip pain; and that prolonged walking increased pain. He also denied falls or injuries to his hips. The examiner noted bilateral hip trochanteric bursitis diagnoses, and opined that the Veteran’s left hip bursitis was less likely proximately due to or the result of the Veteran’s service-connected lumbar spine disability. The examiner explained that the occurrence of hip bursitis increased with age and that repetitive motion was the most common cause. At an August 2019 VA medical examination, the Veteran reported the onset of left hip pain in 2015 with no preceding injury or incident. He also reported no treatments or procedures; that he self-treated with over-the-counter pain relief medication; and that he currently experienced intermittent aching pain in his left hip with stiffness and pain in the early morning. During the examination he reported difficulty after prolonged sitting; difficulty with climbing stairs; difficulty stooping or bending low to the floor; and that he changed his position every 15-20 minutes. The examiner diagnosed the Veteran with trochanteric pain syndrome (to include trochanteric bursitis) as of June 2016. The examiner opined the Veteran’s left hip disability was less likely than not incurred in service, to include due to exposure to gravitational forces as a pilot, because the Veteran did not report any left hip complaints during service or for over 30 years after discharge. The examiner explained that trochanteric bursitis was usually caused by repetitive motion of a joint, trauma or injury to the joint, or advancing age. At an October 2020 VA medical examination, the examiner diagnosed the Veteran with bilateral trochanteric pain syndrome as of 2014, which included trochanteric bursitis. The examiner reviewed medical records of left hip pain and range of motion complaints; the Veteran’s statements during the appeal process; and prior VA medical examinations. The examiner opined the Veteran’s current left hip disability, noted as greater trochanteric pain syndrome or GTPS, was less likely than not caused by his service-connected lumbar spine disability because trochanteric bursitis was a disability caused by acute overload versus a disability caused by degenerative tendinosis. The examiner stated there was no mechanism by which either a remote history of being subjected to high gravitational forces in fighter jets or lumbar degenerative disc disease would cause this condition. The examiner noted medical literature that explained that GTPS was a repetitive overload tendinopathy that suggested that mechanically-induced tissue failure was a key feature of GTPS. In a November 2020 addendum opinion, the examiner opined the Veteran’s left hip disability was less likely than not incurred in service or diagnosed in the presumptive period after discharge because the Veteran’s initial left hip complaints occurred in April 2002, and noted those complaints were not localized to his hips. The examiner also noted that falling on his hips in 2004 likely increased his pain, as did falling off a ladder in 2006. With regards to aggravation, the examiner opined the Veteran’s left hip disability did not demonstrate aggravation beyond the normal progression that was “typically” seen. The preponderance of the evidence is against finding service connection for left hip bursitis or greater trochanteric pain syndrome (GTPS). There is no probative medical evidence that indicates the Veteran’s current left hip disability was incurred in service, diagnosed within the presumptive period after discharge, or was proximately caused by or is being aggravated by his service-connected lumbar spine disability. The Veteran has continuously asserted throughout the appeal that his current left hip disability is a result of the gravitational forces of being a fighter pilot, or alternatively, secondary to his service-connected lumbar spine disability. The Veteran is competent to report observable symptomatology of his condition and to relate a contemporaneous medical diagnosis. See Layno, 6 Vet. App. 465, 469; see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, while the Veteran has attempted to establish a nexus through his own lay assertions, the Veteran is not competent to offer opinions as to the etiology of his current left hip disability. See Jandreau, 492 F.3d 1372, 1377 n.4; Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). Determining the cause of trochanteric bursitis requires specialized training for determinations as to diagnosis and causation, and is therefore not susceptible to lay opinions on etiology. Thus, the Veteran is not competent to render such a nexus opinion or attempt to present lay assertions to establish a nexus between his current left hip diagnosis and its relationship to his service or service-connected lumbar spine disability. In addition, the record contains inconsistent statements regarding the onset of symptoms and the diagnosis and treatment of the disease that minimize the probative weight of the Veteran’s observations of symptoms. At several of the VA medical examinations conducted during the appeal, the Veteran either failed to report that he fell on his hips in 2002 and 2004, or actively denied any falls or precipitating injuries to his hips. Caluza v. Brown, 7 Vet. App. 498 (1995) (holding the Board has a duty to ascertain the credibility of testimony put before it and may consider multiple factors, including inconsistent statements, when weighing credibility.). While VA has a duty to assist the Veteran in developing evidence pertinent to his claim, the Veteran also has a duty to assist and cooperate with VA in developing this evidence. 38 C.F.R. § 3.159 (c). The duty to assist is not a one-way street. See Wood v. Derwinski, 1 Vet. App. 190 (1991). The Board has conducted a thorough medical evaluation into the Veteran’s contentions and further medical inquiry would not substantially assist the Board in its determination. Since the Veteran’s current left hip disability was not incurred in service, diagnosed within the presumptive period after discharge, or was caused or is being aggravated by a service-connected disability, the claim for service connection is denied. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Vito A. Clementi Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Anwar, Attorney-Advisor 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.