Citation Nr: 21026507 Decision Date: 05/03/21 Archive Date: 05/03/21 DOCKET NO. 17-63 759 DATE: May 3, 2021 ORDER 1. Entitlement to service connection for rhinitis is granted. 2. Entitlement to service connection for right hip dysplasia with impingement syndrome (claimed as right hip/leg condition), as secondary to the service-connected disability of right knee fat pad syndrome status-post surgery (right knee disability), is granted. FINDINGS OF FACT 1. The evidence is sufficient to establish that the Veteran's rhinitis is related to her service. 2. The evidence is sufficient to establish that the Veteran's right hip dysplasia is related to her service, as secondary to her service-connected right knee disability. CONCLUSIONS OF LAW 1. The criteria for service connection for rhinitis have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for a right hip dysplasia have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the United States Air Force from June 2010 to February 2011 and is a veteran of the Gulf War Era. This matter comes to the Board of Veterans' Appeals (Board) on appeal of the denial of her claims in a March 2017 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO), which is the agency of original jurisdiction (AOJ). The Veteran and her representative appeared for a videoconference Board hearing with the undersigned Veteran's Law Judge (VLJ) in February 2020 and a copy of the transcript for that hearing has been associated with the Veteran's claims file. Service Connection Generally, service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. 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, 38 F.3d 1163, 1167 (Fed. Cir. 2004)). The absence of any one element will result in denial of service connection. Establishing service connection on a secondary basis requires evidence sufficient to show that (1) a current disability exists and (2) the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 48 (1995) (en banc). 1. Entitlement to service connection for rhinitis. The Veteran seeks entitlement to service connection for rhinitis/ sinus condition which she claims stems from her time in the Air Force. Specifically, she states that during her service stationed in Kuwait she was exposed to sand particles on a daily basis and they embed in her sinus tissues. VA concedes that the Veteran has current diagnoses of chronic sinusitis and allergic rhinitis. The Veteran's military service treatment records (STRs) do contain notations of the Veteran having acute sinusitis and chronic allergic conjunctivitis. See notations October 30, 2010 and December 30, 2010. The Veteran also underwent surgery to repair a broken nasal bone in December 2007. Records from the Veteran's private medical providers at F.M.P.S. indicate she sought service for respiratory and nasal conditions beginning May 2011. These records note in February 2012 an assessment of acute sinusitis. A later diagnosis of recurrent sinusitis was recorded in December 2013. The Veteran was provided a Gulf War illness VA examination in April 2017. Diagnoses of chronic sinusitis and allergic rhinitis were acknowledged. The VA examiner opined that the Veteran's nasal congestion and recurrent sinus infections have a known medical cause and therefore are not medically unexplained chronic multi symptom illness of unknown etiology, stated to be Gulf War illness. The VA examiner also stated there was no evidence in the Veteran's STRs of allergic rhinitis of chronic sinusitis during her military service, and relied on this belief to opine that her rhinitis and sinus conditions are less likely than so (less than 50 percent likely) related to her military service. It is this medical examination and opinion which the AOJ relied on to deny the Veteran's claim. The Board finds the VA examiner's opinion and rationale to be based on an erroneous reading of the evidence, which ignores the entries in the Veteran's STRs which do indicate more than one entry of acute sinusitis and chronic allergic conjunctivitis. Therefore, the Board finds this VA opinion to be of no probative value. Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (medical opinion based upon an inaccurate factual premise has no probative value). During her Board hearing, the Veteran described the conditions of her time in Kuwait while in the Air Force. This included that she was exposed to sand particles on a daily basis and that she started getting sinus infections when she returned home. She also stated that her private medical providers advised her that they found sand particles in her sinuses. The Board finds the Veteran to be competent and credible as to her testimony of her symptoms, facts of events related to her service, and what she was told by medical professionals treating her. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159 (a). Her description of her exposure to sand is consistent with service in the desert country of Kuwait. Based on the evidence of record and giving the Veteran the benefit of any reasonable doubt, the Board finds that the evidence is sufficient to support the Veteran's claim that her current rhinitis/sinus condition was incurred in, and is related to her military service. Her STRs do contain more than one entry of sinusitis, and she sought treatment for sinus and respiratory problems within a month of her separation from service. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran's claim for entitlement to service connection for rhinitis is granted. 2. Entitlement to service connection for right hip/leg condition. The Veteran contends that her current right hip/leg condition is related to, caused by, or aggravated beyond its natural progression by her service-connected right knee disability. VA concedes that the Veteran has a current diagnosis of right hip dysplasia with impingement syndrome (claimed as right hip/leg condition). The Veteran had surgery on her right knee while in service in September 2009. She had a later right knee surgery, post service, in August 2011 for an arthroscopy, chondroplasty of the medial facet of the patella, and debridement of the anteromedial fat pad and scar plica. She was granted service connection for this right knee disability in a September 2016 Board decision. The Veteran was granted service connection for her right thigh muscle atrophy, secondary to her right knee disability, in April 2017. She was also granted service connection for her peripheral neuropathy affecting her right femoral nerve, also secondary to her right knee disability, in January 2019. The Veteran's STRs do not contain complaints of, treatment for, or diagnosis of the claimed right hit/leg condition. This is consistent with the Veteran's assertion that this condition is brought about due to her right knee disability. She was provided a VA examination of her hip and thigh in April 2017. The VA examiner confirmed the diagnosis of right hip dysplasia. The examiner noted that the Veteran stated she began having right hip pain in 2012 which became much worse, described as "unbearable" in 2016, with constant right hip and groin pains and a burning sensation in her buttocks to her hip, and clicking and popping. Physical examination revealed the Veteran complain of pain with palpitation of her anterior (groin area), posterior, and lateral (greater trochanter area) of her right hip. She was noted to meet the criteria set forth in Correia v. McDonald, 28 Vet. App. 158, 168-70 (2016), that there was evidence of pain on passive range of motion testing, in weight-bearing and non-weight-bearing, and, that the opposite joint was undamaged. See also 38 C.F.R. § 4.59. However, no functional limitations due to her right hip condition were noted by the VA examiner. The VA examiner opined that the Veteran's right hip disability was not an undiagnosed illness, a diagnosable but medically unexplained chronic multi-symptom illness of unknown or partially explained etiology, and not related to a specific exposure, event, or environmental hazard experienced during active service in South West Asia. In a separate medical opinion of the same date, the VA examiner opined that the Veteran's right hip/leg condition is less likely than so (less than 50 percent) proximately due to or the result of the Veteran's service-connected right knee disability. This was based on the rationale that her right thigh muscle atrophy suggested less use of the right thigh, which would correlate to a decreased probability of a right hip condition due to her right knee condition which started in 2001; and that her right hip dysplasia is a congenital abnormality, not caused by her service connected right knee. Thereafter, the Veteran underwent right hip surgery in January 2020, performed by her private medical provider, Dr. S.A. The surgery performed was a right hip arthropathy, osteoplasty of the femoral neck and acetabulum, with spinoplasty, labral repair, capsular plication. and loose body removal. The pre-operative diagnosis was femoral acetabular impingement, labral tear, and laxity of the right hip. The Veteran provided a medical opinion letter from H.C., ARNP, who opined that it is at least as likely as not that the Veteran's current right hip femoral acetabular impingement is due to her service-connected right knee and thigh condition. H.C. noted that the Veteran continued to have pain in her right knee since her right knee surgeries. This condition was noted to be a chronic condition in an August 2013 VA primary medical provider care note. She also described the history of the Veteran's right hip pain with clicking and popping, which began in 2012, and interferes with her daily activities and causes functional impairment such as difficulty with running, squatting, distance ambulation, prolonged sitting and/or standing, driving, getting in or out of vehicles, and ascending or descending stairs. She is also unable to lie on her right side. The Veteran worked as a Police officer post-service and indicts that she had to quit her job due to the right hip issues, and her inability to meet other physical requirements, taking a desk job. H.C. further cited medical references which support the progression that femoral acetabular impingement is the most common cause for labral tears with successive progress in degeneration. H.C. also referenced studies which support that patients with fat pad removal surgeries and anterior knee pain/scarring are also associated with quadriceps atrophy, which exacerbates the progression and degeneration of the hip. H.C. relates that the Veteran's right knee pain and other problems began in and continued after her separation from the military, which included knee and leg weakness that ascended to her right thigh, causing the atrophy for which she is service-connected. This has led to the right hip problems which H.C. stated are "clearly associated with the right thigh atrophy and chronic knee condition." During her Board Hearing, the Veteran confirmed the history and progression of her right knee injury, and subsequent surgeries, as well as the following progression of problems with her right thigh, nerves, and her right hip, which recently required surgery. The Veteran also described her symptoms, pain, and the functional impact of these conditions, including the need for her to leave her position as a police officer to take a less physically demanding desk job. The Board finds the Veteran to be competent and credible in her testimony and statements which are consistent with the other evidence in the record. Jandreau, 492 F.3d at 1377; 38 C.F.R. § 3.159 (a). Based on the evidence of record and giving the Veteran the benefit of any reasonable doubt, the Board finds that the evidence is sufficient to support her claim that her right hip/leg condition was caused or aggravated by her service-connected right knee and/or right thigh atrophy disabilities. The Veteran's right knee problems clearly began in service, and there is an undeniable pattern of progressive degeneration of her right leg and hip, for which she has been granted service connection. The Board finds the VA examiner's opinions to be of little probative value at this time, if any, due to the fact that they do not take into consideration the full set of facts which have developed since they were authored. Further, VA examiner's opinion that the Veteran's right hip dysplasia is a congenital abnormality, not caused by her service-connected right knee, did not take into consideration the September 2016 Board decision which addressed an earlier VA examiner's assertion in September 2012 that the Veteran's right knee problem pre-existed her entry into service. In our earlier decision, the Board found that the Veteran was considered to be in sound condition when she entered into service, and therefore, her knee disability was not a pre-existing condition. 38 U.S.C. § 1111; 38 C.F.R. § 3.304. The same must be found concerning the Veteran's right hip condition as there was no notation of the claimed congenital defect in her entrance examination documents, nor any clear and unmistakable evidence which demonstrates the injury existed prior to service. Id. Further, the medical evidence is at least in equipoise that her right hip/leg condition was aggravated beyond its natural condition due to the Veteran's other right knee and leg service-connected disabilities. The Board finds the medical opinion of H.C. to be of significant probative value as it addressed the Veteran's medical condition as it had developed to that point and took into consideration the medical records of Dr. S.A., who performed the right hip surgery. H.C's opinion was well supported by both the facts of record and the Veteran's testimony available at the time, and provided a well-reasoned analysis of the development of the condition from her right knee to her right hip, including citations to and analysis of published medical references. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53. The Veteran's claim for entitlement to service connection for her right hip/leg condition is granted. R. FEINBERG Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Bannach, 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.