Citation Nr: 21022929 Decision Date: 04/19/21 Archive Date: 04/19/21 DOCKET NO. 13-31 803 DATE: April 19, 2021 ORDER Entitlement to service connection for a left hip disability (dislocated left hip and left hip degenerative joint disease) is denied. FINDINGS OF FACT 1. The Veteran’s left hip dislocation pre-existed service and did not permanently increase in severity during service. 2. The preponderance of the evidence is against a finding that the Veteran’s left hip degenerative joint disease (DJD) manifested in active service or within one year after service or is otherwise related to his military service. CONCLUSIONS OF LAW 1. The Veteran’s pre-existing left hip dislocation was not aggravated during active service. 38 U.S.C. §§ 1110, 1131, 1132, 1153, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.306. 2. The criteria for service connection for left hip DJD are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1978 to March 1982. The matter comes to the Board of Veterans’ Appeals (Board) from a decision of the Agency of Original Jurisdiction (AOJ). In July 2012, the AOJ issued a rating decision that denied the Veteran’s claims for service connection for a left hip disability and an acquired psychiatric disorder. The Veteran timely disagreed in a February 2013 Notice of Disagreement (NOD) and perfected his appeal in October 2013 and January 2014 VA Form 9s. The Board notes the Veteran’s claim has been remanded to the AOJ several times. Most recently, in March 2020 for new disability examinations. In October 2020 and January 2021, new VA disability examinations were conducted. Later in January, the AOJ re-adjudicated the Veteran’s claims. The AOJ granted service connection for post-traumatic stress disorder (PTSD) and assigned a disability rating of 50 percent under Diagnostic Code (DC) 9411. His claim for service connection for a left hip disability was denied. So, the remaining issue on appeal is the left hip disability claim. In February 2021, the Veteran’s case was returned to the Board. 1. Entitlement to service connection for a left hip disability. The Veteran contends his current left hip disability is related to running in leather boots while in service. See January 2011 Statement in Support of Claim at 2. He also contends he dislocated his left hip before entering service and it worsened during service. See January 31, 2014, VA Form 9 at 1. The question for the Board is whether the Veteran’s pre-existing left hip dislocation is the same condition as his left hip DJD. If not, the question becomes whether the Veteran’s pre-existing disability increased in severity during active service. Also, whether his left hip DJD is related to his service. For the reasons discussed below, the Board concludes the Veteran’s left hip dislocation and left hip DJD are two different disabilities. The Board also concludes the evidence does not support finding his dislocated hip was aggravated by his service. Also, his left hip DJD is not related to his service. Entitlement to service connection requires a Veteran to provide evidence of three elements: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or nexus between the current disability and the disease or injury incurred or aggravated during active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a); Shedden v. Principi, 381 F.3d 1163, 1166-67 (2007). Another way a Veteran can establish service connection is by satisfying the test for disability compensation for chronic diseases set forth in 38 C.F.R. § 3.303(b). Walker v. Shinseki, 708 F.3d 1331, 1334 (2013). To satisfy that test the Veteran must (1) have a chronic disease listed under § 3.309(a) and (2) that disease must have been “shown in service.” Id. at 1335. As to (1), arthritis, to include DJD, is listed under § 3.309(a). As to (2), to be “shown in service” requires a combination of manifestations sufficient to identify the disease entity and “sufficient observation to establish chronicity at the time.” Walker, 708 F.3d at 1335. If the Veteran satisfies the test for disability compensation for chronic diseases in 38 C.F.R. § 3.303(b), the Veteran is relieved of the requirement to show a causal relationship between the condition in service and the condition for which disability is sought. Walker, 708 F.3d at 1335. In order to prevail on a claim for benefits, the Veteran need only demonstrate there is an approximate balance of positive and negative evidence. Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). This is because the Veteran is entitled to the “benefit of the doubt” when the evidence is approximately balanced. Id. at 53. But, if a preexisting condition is noted upon entry into service, “the [V]eteran cannot bring a claim for service connection.... but the [V]eteran may bring a claim for service-connected aggravation of that disorder.” Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). A preexisting injury or disease will be considered to have been aggravated by active military, naval, or air service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 C.F.R. § 3.306(a). Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during and subsequent to service. 38 C.F.R. § 3.306(b). Beginning with the Veteran’s service, the Veteran’s entrance examination notes the Veteran had left hip surgery in 1972. Part of the examination includes a questionnaire where the Veteran is asked to report any prior medical conditions he had before service, he reported he dislocated his left hip. See February 17, 1978, Report of Medical Examination at 2; February 17, 1978, Report of Medical History at 2. A month after entering service, a military doctor evaluated the Veteran’s reports of a dislocated hip. A lot of the report is hard to read but on the fourth line it states, “he has no complaints re: the left hip now.” On line six, it states “well healed.” See March 2, 1978, Clinical Record. The Veteran’s service treatment records (STRs) do not note any complaints associated with a left hip problem. Before leaving service, the Veteran underwent a separation examination. At that time, he reported “bone, joint, or other deformity” as well as another unrelated condition. Due to the quality of the scanned document, a lot of the writing is hard to read. But some of it is legible, to include the words “Orthopedic Hospital, 1971, . . . Dislocated hip, Dr. Fugo.” The miliary doctor who evaluated the report noted some medical abbreviations related to another reported (and unrelated) medical condition. See January 8, 1983, Report of Medical Examination at 2. Several years after leaving service the Veteran reported complaints of hip pain associated with a left hip injury as a child. He reported that when he was a child he slipped on ice and dislocated his hip. He added that he has observed hip pain for around 20 years. See April 25, 2006, VA Medical Center (VAMC) record by R.R.L., PA; May 23, 2006, Record by A.F.K., NP. The Veteran was diagnosed with left hip DJD that around the time he reported complaints of hip pain. The record reflects it was confirmed by X-ray imaging. See May 23, 2006, VAMC Record by A.F.K., NP. Then, in December 2011, the Veteran underwent his first disability examination to evaluate his hip disability. The Veteran reiterated that he dislocated his left hip before entering service. He added that the pain resolved before his service. But, during service he started to observe hip pain when he ran in his boots. He reported his left hip pain continued to progress over time: Now, it is constant. At the time of this examination, the only left surgery the Veteran was the one in 1971/1972. See December 2011 VA DBQ at 1, 2. The examiner noted the diagnoses of left hip degenerative arthritis and slipped capital femoral epiphysis left hip. The date of diagnosis of arthritis was 2008 and the date for slipped capital femoral epiphysis was 1972. Id. at 1. Then, the examiner concluded that the Veteran’s symptoms indicate the two diagnosed conditions are part of the same medical condition. That is, the dislocated hip that pre-existed service naturally progressed into degenerative arthritis. The examiner also concluded it is a pre-existing disability that was not aggravated by his service. Id. at 12. Later, in May 2018, the Board found the examiner’s opinion inadequate to decide the claim. The Board explained that the record reflects the Veteran may be discussing more than one disability: he reported his pre-existing condition resolved and also stated his current hip condition had its onset during service. Also, it was unclear if the examiner considered that the Veteran’s pre-existing disability may not be the same medical disability he was referring to when discussing his observations during service. So, the Veteran’s entitlement claim was remanded for another opinion. See May 2018 Board Remand at 3. In November 2019, the Veteran underwent another VA disability examination to evaluate his reported left hip conditions. He reported that, in the Marines, he did a lot of walking and running. He added that his left hip pain gradually developed. But he did not report those pains to a service medical provider. Then, many years after service, a private doctor told him he had lost cartilage in his left hip. See November 2019 VA DBQ at 2. He added that, after reporting complaints of hip pain to the VA, he was diagnosed with arthritis and had a left hip replacement in 2014. The Veteran reported he no longer has hip pain. Id. The examiner noted the diagnoses of left hip osteoarthritis and “left hip disability.” The date of diagnosis for the left hip disability was “late 1970s to early 1980s.” The date of diagnosis for arthritis was 2008. Id. at 1. After concluding the Veteran has two conditions, the examiner indicated one preexisted service and the other began after service. She indicated that the left hip disability preexisted service and did not increase in severity during service. The examiner indicated her opinion was, in part, based on the Veteran’s report that the other diagnosed condition, the left hip disability, worsened after service. Id. at 12, 13. The examiner concluded the Veteran’s left hip arthritis is not related to his service. She opined that it did not manifest during service or within one year after leaving service. The examiner concluded the Veteran’s arthritis is due to the aging process. Id. After the VA received the November 2019 medical opinion, the Board determined it was not adequate to decide to the claim. The Board explained that it was not clear if the examiner considered a lay statement in the record. Specifically, that the Veteran’s pre-existing left hip condition worsened after entering service. The Board remanded the Veteran’s claim for another medical opinion. See March 2020 Board Remand at 2, 3-4. Later, in January 2021, the Veteran underwent his most recent VA disability examination for his hip disability. The Veteran reiterated that he dislocated his left hip and, in 1971, underwent surgery to secure it in place. He reported it got worse during service due to running with heavy boots. Now, he observes some left hip pain. See January 2021 VA DBQ at 3. The examiner noted the Veteran’s dislocated left hip stayed the same since its onset in the late 1970s. The examiner also noted the diagnosis of hip replacement status post. He noted the date of diagnosis is 2014. Id. at 1, 3. Then, the examiner prepared a medical opinion. The examiner concluded that the Veteran’s left hip DJD hip is not the same condition as the one noted at entrance. The examiner’s reason for viewing them as separate conditions is that the Veteran reported his dislocated hip had resolved before entering service. Also, the first confirmed diagnosis of DJD occurred long after leaving service. See January 2021 Medical Opinion at 4. As to the dislocated hip, the examiner found there is clear and unmistakable evidence it had pre-existed service. He pointed to the Veteran’s own statements at entrance reporting a medical procedure on the left hip. As to whether it was aggravated during service, the examiner concluded it was not. The examiner noted the Veteran’s left hip disability is due to its natural progression. Id. The examiner also opined on whether the Veteran’s left hip DJD is directly related to his service. The examiner explained that the evidence of record does not indicate the presence of DJD during service. He also indicated that because the Veteran’s left hip DJD was diagnosed after service, it is unlikely that it is related to his service. Id. at 2. A. Whether the Veteran’s entitlement claim involves one disability, or two separate ones. Since there are conflicting medical opinions on the number of disabilities involved in this case, the first question is whether the left hip dislocation noted at entry is the same disability as the left hip DJD that was diagnosed later in time. The Veteran’s lay statements and observations are of little probative value on this issue. The determination as to whether his dislocated hip is the same condition as his arthritis is a complex medical question which he has not alleged he is qualified to make. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (2007). The December 2011 VA medical opinion concluded the Veteran’s left hip dislocation and arthritis are the same condition; however, the opinion was assigned little to no probative value. In that opinion, the examiner explained that he considered the Veteran’s reports at entrance and during his personal examination when rendering his conclusion. See Medical Opinion at 2. The Board notes that the Veteran’s assertions suggest the hip condition during service may not be the same condition he reported on at entrance. That determination was based on the Veteran’s report that the disability he seeks compensation for began during service. See May 2018 Board remand at 2-3. Even though the examiner is qualified to conclude they are the same condition, he must support the conclusion with a reasoned explanation. Nievez-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2006). Because the examiner neither discussed that statement nor addressed it in his opinion, the Board was unable to determine whether the evidence he relied on connects to it. Id. So, the Board found it insufficient to decide the claim. Since the Board cannot evaluate how he determined the Veteran’s entitlement claim involves one disability, it now finds the opinion is of little to no probative value on this issue. The January 2021 medical opinion weighs strongly in favor of finding the Veteran’s left hip disability claim involves two different hip conditions. The examiner considered that the Veteran reported his dislocated hip had resolved prior to entering service. The examiner also considered his review of the record, personal examination, and the Veteran’s observations. So, the Board finds the examiner was informed of the relevant details of the Veteran’s past medical history when rendering his opinion. Nievez-Rodriguez, 22 Vet. App. at 301. The examiner provided an adequate explanation for concluding the Veteran’s left hip arthritis is not the same as the dislocated hip noted at entrance. The examiner indicated he relied on the evidence generated at the time of entrance, to include the Veteran’s statements, to determine the dislocated hip resolved before entering service. The examiner then indicated the large gap in time between the Veteran’s entry into service and the first confirmed diagnosis of arthritis supported finding the two hip conditions are not related. See January 2021 VA Medical Opinion at 2, 4. The Board finds the examiner’s explanation sufficient to evaluate whether the data he relied on connect to his conclusions. Nievez-Rodriguez, 22 Vet. App. at 301. Because the examiner had the benefit of the ability to consider the opinion of other examiners on the issue when coming to his conclusion, the opinions was assigned significant weight. Even though the examiner did not explain what caused the Veteran’s left hip arthritis, it is apparent to the Board he concluded it was not related to the hip dislocation noted at entry. He made that clear in the portion of his opinion where he asserts the Veteran’s left hip DJD is “separate and different” from the hip condition noted at entry. See January 2021 Medical Opinion at 4. So, the Board finds the lack of a conclusive etiology does not diminish probative value of the opinion on this issue. In this case, the evidence weighs in favor of finding the Veteran’s left hip dislocation noted at entry is not the same condition as his left hip DJD. Although the December 2011 opinion concluded they were the same, there were deficiencies in the decision which prevented it from being assigned more than a little probative weight. It was outweighed by the more probative January 2021 opinion, which concluded the Veteran has two separate left hip conditions. So, the Board finds the Veteran left hip disability entitlement claim involves two hip conditions: the hip dislocation noted at entry and left hip DJD. Because the Board has determined there are two left hip conditions, they will be addressed separately. B. Presumption of aggravation for a pre-existing condition. Now that the Board has determined the Veteran’s left hip dislocation is not the same disability as his left hip DJD, the next question is whether his dislocated hip was aggravated by his service. To answer that question, the first issue is whether the Veteran’s dislocated hip was noted at the time he entered service. The record reflects several documents generated at the time of the Veteran’s entrance that identify he underwent left hip surgery due to a dislocated hip before entering service. Those records include his report of the surgery and confirmation by two medical doctors who evaluated hi report. Together, the records provide sufficient evidence to find a left hip condition was noted at entry. See February 17, 1978, Report of Medical History; February 17, 1978, Report of Medical Examination at 2; March 2, 1978, Clinical Record. If there is any question about the sufficiency of the entrance exam to find the Veteran’s dislocated hip preexisted service, a VA examiner has concluded it is clear and unmistakable evidence that the Veteran had a left hip condition at entrance. The examiner indicated that the Veteran’s reports and medical records generated at the time of entrance provide undebatable evidence his dislocated hip was noted at entrance. See January 2021 VA Medical Opinion at 4. In this case, the Board finds the Veteran’s entrance exam noted he had dislocated his hip before entering service. Because the January 2021 medical opinion has also determined there is clear and unmistakable evidence it had pre-existed service, there is no doubt to be resolved in the Veteran’s favor. The next issue is whether the Veteran has established that his disability increased in severity during service. The December 2011 opinion weighs against finding that the Veteran’s dislocated hip worsened during service. Although it is unclear if the examiner considered that the Veteran’s dislocated hip is a different condition than the one he seeks VA disability benefits for, the Board finds it is unlikely that consideration of two conditions would have changed the examiner’s opinion on this issue. If the examiner viewed the Veteran’s left hip disability claim as involving one condition, he associated all the evidence of record with his dislocated hip and concluded it had not worsened during service. To evaluate them as two conditions, the examiner would have to associate fewer symptoms with Veteran’s dislocated hip. That results in a disability picture that is less severe than the one he had in mind when evaluating one condition. Because he did not find it had worsened when associating the evidence of record with one condition, it is unlikely he would have changed his opinion when associating part of the record with the same condition. The Board recognizes the December 2011 opinion was found to be insufficient to decide the claim. As noted, it was because it is unclear if the examiner considered that the Veteran’s hip dislocation may not be the same condition he reported on during service. So, it is unclear what evidence the examiner would have associated with the Veteran’s dislocated hip. Because that is relevant to understanding how he determined it has not increased in severity during service, the opinion was assigned little probative value. The January 2021 opinion weighs strongly against finding the Veteran’s dislocated hip worsened during service. The examiner explained that the Veteran’s dislocated hip “resolved” before entering service. See Medical Opinion at 4. That means it returned to its normal state. DORLAND’S ILLUSTRATED MEDICAL DICTIONARY (DORLANDS) 1602 (33rd ed. 2020). Despite that conclusion, the examiner indicated he searched the record for evidence it had worsened: He concluded it had not. Instead, he concluded the Veteran’s dislocated hip did not worsen until several years after leaving service. See Medical Opinion at 4. The examiner also acknowledged and considered the Veteran’s reports of problems with his left hip while in service. See January 2021 VA DBQ at 3. As noted above, the examiner concluded the Veteran’s dislocated hip did not become problematic during service. So, he viewed the Veteran’s observations of hip pain from running in boots with a different condition. Because the examiner is qualified to opine on whether the Veteran’s observations are related to his dislocated left hip as well as whether it worsened during service, the Board finds the explanation sufficient to evaluate whether the information he relied on connects to his conclusion. Nievez-Rodriguez, 22 Vet. App. at 301. Considering the examiner addressed several questions from the Board to ensure it was able to make a fully informed decision, the opinion was assigned great weight. The Board notes the examiner’s conclusion is supported by the Veteran statements during the November 2019 VA disability examination. The examiner who conducted that examination noted the Veteran reported his dislocated hip worsened after service, in the 2000s. See VA DBQ at 12. Even though the medical opinion that followed the November 2019 examination was found inadequate, the Veteran’s lay assertions during the exam remains credible evidence that can support another opinion. The Veteran’s lay statements weigh against finding his dislocated hip worsened during service. The Veteran has personal knowledge of whether he observed symptoms, like pain. So, he is competent to report it. Layno v. Brown, 6 Vet. App. 465, 467-70 (1994). Here, the record reflects the Veteran has told one VA examiner he observed hip pain during service. Then later told two examiners his dislocated hip did not worsen until several years after service. See January 2011 Statement in Support of Claim at 2; December 2011 VA DBQ at 1-2; November 2019 VA DBQ at 12; January 2021 VA Medical Opinion at 4. Although the Veteran’s lay observations appear inconsistent, their conflict is reconciled when they are viewed as describing two separate hip conditions: his dislocated left hip and left hip DJD. Based on the January 2021 medical opinion, his observations during service are not related to his dislocated hip. See Medical Opinion at 3, 4. Relying on the examiner’s conclusion, the Board finds the relevant reports are that his dislocated hip resolved prior to entering service then worsened many years after service. Those reports indicate there was a period of time from the beginning of his service, through service, then several years after service when his dislocated hip had not worsened. Because reports to medical providers are generally viewed as reliable, his statements were found credible and assigned significant weight. In this case, the evidence weighs against finding the Veteran’s dislocated hip worsened during service. The examiner who prepared the highly probative January 2021 opinion evaluated the relevant lay observations with the evidence of record and determined the Veteran’s dislocated hip resolved before entering service. Also, it did not worsen until around the 2000s. The examiner’s conclusion is supported by the December 2011 opinion, which also found the Veteran’s dislocated hip did not increase in severity during service. So, doubt could not be resolved in the Veteran’s favor. Gilbert, 1 Vet. App. at 54. Because the Board finds the Veteran’s dislocated hip had not worsened during service, an increase in severity has not been shown. So, the presumption of aggravation does not attach, and his dislocated hip will not be considered to have been aggravated by his military service. 38 C.F.R. § 3.306(b). Even though the evidence does not support finding the Veteran’s dislocated hip worsened during service, the Board notes the January 2021 medical opinion concluded there is clear and unmistakable evidence that any increase in disability was due to the natural progress of the disease. The examiner indicated that a dislocated left hip could become problematic later in life. Also, it is part of the natural course of the condition to need a hip replacement later in life. See Medical Opinion at 2, 4. The Board finds the explanation sufficient to evaluate whether the information the examiner relied on connects to his conclusion. Nievez-Rodriguez, 22 Vet. App. at 301. Considering the examiner had the benefit of the opinions of other VA examiners before rendering his conclusion, his opinion was assigned significant weight. In sum, the evidence supports finding the Veteran’s dislocated hip pre-existed service. But it does not support finding it worsened during service. So, he has not established entitlement to service connection under 38 C.F.R. § 3.306. C. Entitlement to service connection for left hip DJD on a direct basis. Since the Board has found the Veteran’s left hip DJD is not the same medical condition as his dislocated hip, the question is whether the Veteran has established entitlement to service connection under 38 C.F.R. § 3.303(a) for left hip DJD. That is, on a direct basis. To answer that question, the first issue is whether the Veteran’s left hip DJD is a current disability. The record reflects several diagnoses of left hip DJD throughout the appeal period, recently during the November 2019 disability examination. See VA DBQ at 1. So, the record reflects a diagnosed left hip disability during the appeal period. The next issue is whether the Veteran’s left hip DJD (left hip disability) began in or was incurred during service. The Veteran’s statements weigh in favor of finding his right hip disability began during service. The Veteran has personal knowledge of symptoms, like pain. So, he is competent to report it. Layno, 6 Vet. App. at 469. Here, the relevant statements indicate he observed left hip pain shortly after entering service and gradually progressed to constant pain up to his 2014 reconstruction surgery. Then after surgery he observed less pain. See December 2011 VA DBQ at 1; November 2019 VA DBQ at 2; January 2021 VA DBQ at 3. Although the Board finds his reports of pain credible, it is a general symptom that can indicate many different conditions. So, without more, those observations are not sufficient to reliably identify the presence of arthritis. But because they remain probative evidence that may support a later diagnosis, his statements were assigned some, but not, significant weight in favor of an in-service incurrence. The January 2021 VA medical opinion weighs strongly against finding the Veteran’s left hip disability began during service. The examiner considered the Veteran’s reports of pain with the rest of the evidence of record and concluded the Veteran had not developed arthritis during service. Because the examiner is qualified to evaluate whether the evidence of record indicates the presence of arthritis, the Board finds the explanation sufficient to evaluate whether the information he relied on connects to his conclusion. Nievez-Rodriguez, 22 Vet. App. at 301. So, the examiner’s opinion was assigned significant weight against the presence of arthritis during service or within one year from leaving service. In this case, the evidence weighs against finding his left hip disability began in or was noted during service. Although the Veteran reported general observations of pain, they are not sufficient to constitute a reliable diagnosis of arthritis. But the examiner who prepared the more probative January 2021 opinion is: He concluded the evidence of record, to include the Veteran’s observations, do not show the presence of arthritis during service. So, doubt on the issue could not be resolved in the Veteran’s favor. Gilbert, 1 Vet. App. at 54. The next issue is whether there is a nexus between the Veteran’s left hip disability and his active service. Although the Veteran is competent to report symptoms of pain, he is not competent to opine on the presence of arthritis. That is because providing a reliable diagnosis of arthritis is a medical question that requires ruling out other potential medical conditions. Clinical Manifestations and Diagnosis of Osteoarthritis, UpToDate.com, https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-osteoarthritis?search=Osteoarthritis&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2 (last visited April 12, 2021). Also, a valid diagnosis of arthritis must be confirmed by X-ray imaging. 38 C.F.R. § 4.17a, Diagnostic Code 5003. So, his lay opinions on the presence of arthritis could not be considered. Even though his opinions on arthritis were not considered, his statements remain competent and credible evidence that support a later diagnosis. Jandreau, 492 F.3d at 1377. The January 2021 medical opinion weighs strongly against finding his left hip disability is related to his service. As noted above, the Board finds the examiner was informed of the relevant details of the Veteran’s past medical history when rendering his opinion. Nievez-Rodriguez, 22 Vet. App. at 301. The examiner indicated that, despite the Veteran’s reports of pain during service, the evidence of record did not support finding a left hip disability during service. As explained above, he concluded the evidence did indicate the presence of arthritis during service. See January 2021 VA Medical Opinion at 2, 4. The examiner also indicated he considered whether the Veteran’s activities during service are related to the development of arthritis after service. Although the examiner did not discuss the effects of strenuous activity, like running in boots, the examiner noted those activities during his personal examination of the Veteran. See January 2021 VA DBQ at 3. So, his conclusion that the Veteran’s left hip disability is not related to service implies he considered a causal connection between them. Also, the examiner provided a reasoned explanation for his conclusion. He indicated the large gap in time between his activities during service, like running in boots, and his first confirmed diagnosis of arthritis shows they are not related. See January 2021 VA Medical Opinion at 2, 4. The Board finds his explanation sufficient to evaluate whether the information he relied on connect to his conclusions. Nievez-Rodriguez, 22 Vet. App. at 301. So, on its own, the opinion has significant probative value. The examiner’s conclusion is supported by the November 2019 opinion. The examiner who prepared that opinion attributed his left hip arthritis to aging. See VA DBQ at 12, 13. Considering another medical professional who evaluated the question of a nexus also determined there is not one, it adds to the probative weight assigned to the January 2021 opinion. The Board recognizes the November 2019 opinion was found to be inadequate; however, that finding related to the portion of the opinion that opined on his dislocated hip—not arthritis. So, the part of the opinion that relates arthritis remains probative evidence. Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) (noting that, although a medical examination may be deemed inadequate in part, the parts that are adequate cannot be completely ignored, and they still hold probative value). In this case, the evidence is not approximately balanced on this issue of a nexus. Although the Veteran provided general reports of pain, the examiner who prepared the January 2021 opinion concluded it did not indicate the presence of DJD. Nor did the Veteran’s activities cause it. Considering another medical professional came to the same conclusion, doubt on this issue could not be resolved in the Veteran’s favor. Gilbert, 1 Vet. App. at 54. As a result, the Board finds there is no nexus between the Veteran’s left hip disability and his service. Since the Veteran has not established a nexus nor an in-service incurrence, he has not established entitlement to service connection under 38 C.F.R. § 3.303. C. Entitlement to service connection based on a chronicity and continuity of symptomatology. The next question is whether the Veteran has established entitlement to service connection under 38 C.F.R. § 3.303(b). That is, based on chronicity or continuity of symptomatology. The first issue is whether the Veteran has a chronic disability under VA regulations. The Veteran’s diagnosed left hip DJD is a disability that falls within 38 C.F.R. § 3.309(a). Thus, the record reflects the Veteran has a chronic disability.  Although the record reflects a diagnosed chronic disability, the Board has found it was not shown in or noted during service. As explained above, the evidence in the record does not support finding he had a diagnosis of arthritis during service. Nor within one year after leaving service. See January 2021 Medical Opinion at 2, 4. In this case, the evidence is not approximately balanced in favor of finding the Veteran’s chronic disability was shown in service. There is not enough evidence of a reliable diagnosis of a chronic disability during service. Walker, 708 F.3d at 1335. So, doubt could not be resolved in the Veteran’s favor. Gilbert, 1 Vet. App. at 54. As to continuity of symptomatology, the first issue is whether the Veteran’s diagnosed arthritis was shown in or noted during service. As explained above, the Board has found it was not. Even though the Veteran has not satisfied the first issue, the Board notes the Veteran did not provide sufficient evidence to relate his diagnosed DJD to continuous symptoms of that disability since service. The Veteran’s report of progressive pain since service weighs in favor of finding continuous symptoms. The Veteran has personal knowledge of symptoms, like pain. So, he is competent to report it. Layno, 6 Vet. App. at 469. Here, he reported his pain began shortly after service and gradually progressed to the point it was constant. See December 2011 VA DBQ at 1. As explained above, general reports of pain are not enough to establish the presence of arthritis. So, his statements were assigned some, but not significant, weight in towards establishing continuous symptoms of arthritis. The examiner who prepared the January 2021 opinion considered the Veteran’s reports of pain but concluded the Veteran developed arthritis several years after service. More importantly, he concluded the Veteran’s service did not cause his DJD. Because the examiner is qualified to opine on the cause of the arthritis, the Board assigned the opinion significant weight against finding continuous symptoms of arthritis since service or within one year of leaving service. Nievez-Rodriguez, 22 Vet. App. at 301. In this case, the evidence is not approximately balanced in favor of finding he has observed continuous symptoms of arthritis since service. Although the Veteran’s observations can support a later diagnosis of arthritis, the examiner who evaluated his observations concluded they do not. So, doubt could not be resolved in the Veteran’s favor. Gilbert, 1 Vet. App. at 54. As a result, the Veteran has not established entitlement to service connection based on continuity of symptomatology. 38 C.F.R. § 3.303(b). In sum, the Veteran has not established entitlement to service connection under 38 C.F.R. §§ 3.303(a) or (b). The Board regrets a more favorable decision could not be reached in the Veteran’s case. DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Dean, Michael S. 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.