Citation Nr: 21031851 Decision Date: 05/24/21 Archive Date: 05/24/21 DOCKET NO. 14-41 162A DATE: May 24, 2021 ORDER Entitlement to service connection for osteoarthritis of the bilateral hips, as secondary to service-connected spondylosis of the lumbar spine, is granted. REMANDED Entitlement to service connection for hypertension, to include as secondary to spondylosis of the lumbar spine, is remanded. Entitlement to service connection for a bilateral wrist disability is remanded. FINDING OF FACT The Veteran's osteoarthritis of the bilateral hips is proximately due to her service-connected spondylosis of the lumbar spine. CONCLUSION OF LAW The criteria for service connection for osteoarthritis of the bilateral hips, as secondary to spondylosis of the lumbar spine, are 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 had active service from August 1980 to December 1990. This matter comes before the Board of Veterans' Appeals (BVA or Board) from October 2011 and August 2013 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran requested a hearing before the Board. The requested hearing was conducted in April 2018 by the undersigned Veterans Law Judge. A transcript is associated with the claims file. In June 2018 and January 2021, the Board remanded these claims for additional development. Service Connection 1. Entitlement to service connection for a bilateral hip disability. The Veteran seeks entitlement to service connection for a bilateral hip disability. She asserts her bilateral hip disorder is due to her back disability. In general, service connection requires competent evidence showing: (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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 4 (1990). Equal weight is not necessarily accorded to each piece of evidence contained in the record; not every item of evidence necessarily has the same probative value. Furthermore, in determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of matter, the benefit of the doubt will be given to the Veteran. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. As service connection for a bilateral hip disability is being granted on a secondary basis based on causation, there is no need to discuss entitlement to service connection on a direct basis or any other basis. Service connection may be granted for a disability that is proximately due to, or aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310. The Veteran has a current diagnosis of osteoarthritis of the bilateral hips. See Disability Benefits Questionnaire (DBQ) received in March 2021. The Veteran is service connected for spondylosis of the lumbar spine. See August 2013 rating decision. The key question at issue is whether the Veteran's bilateral hip disorder is caused or aggravated beyond its natural progression by the Veteran's service-connected lumbar spine disability. A private medical opinion was received in March 2021. The physician indicated that the Veteran's records were reviewed and opined that it is more likely than not that the Veteran's bilateral hip osteoarthritis is proximately due to her service-connected lumbar spine. The physician explained that the opinion was based on the Veteran's lumbar pathology as well as the progressive deterioration that has impacted the femoral acetabular joint due to improper biomechanics of the lumbar spine putting high stress forces on the femoral acetabular joint of the hips. The physician stated that chronic, long-lasting hip conditions often occur due to repetitive stress over a long duration of time, and in the Veteran's case, the compression or wearing of the joint is occurring at the soft tissue of the femoral acetabular joints. It was noted that when the condition is bilateral, as here, it is suspect of a more long-lasting pathology that has been progressing over time due to microtraumas, such as improper gait and station due to lumbar spine pathology. The physician then referenced a study regarding gait adaptations in regard to lumbar spine pathology and indicated that the Veteran's overcompensation has likely developed similarly. The Board acknowledges that a VA medical opinion was obtained in February 2018, at which time the VA examiner opined that the Veteran's hip disorder is less likely than not secondary to her lumbar spine disability. The examiner explained that medical literature does not support a clear causative mechanism between lumbar pathology and over use type bilateral hip injury; moreover, the Veteran's residual lumbar function, while imperfect, is still within a functional range is unlikely to cause or aggravate a bilateral hip pathologic process. The Board finds the private medical opinion is at least as probative and persuasive as the VA opinion. The private physician reviewed the Veteran's files and included a rationale with the opinion that explained the relationship between the Veteran's service-connected lumbar spine disability and her claimed bilateral hip disability. The Board finds no adequate basis to reject the evidence of record that is favorable to the Veteran, based on a lack of credibility or probative value. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997); Evans v. West, 12 Vet. App. 22, 26 (1998). In light of the discussion above, while the evidence is not unequivocal, it has nonetheless placed the record in at least relative equipoise. As such, the Veteran's service-connection claim for a bilateral hip disability, on a secondary basis, is granted. REASONS FOR REMAND 2. Entitlement to service connection for hypertension, to include as secondary to service-connected spondylosis of the lumbar spine. The Veteran seeks entitlement to service connection for hypertension. Of note, the Veteran submitted a private medical opinion, received in November 2019, at which time the private physician opined that "it was within reasonable medical probability that her chronic back pain exacerbates her blood pressure." However, the physician did not provide a baseline of the severity of the Veteran's blood pressure prior to the aggravation and did not provide any further rationale. Additionally, a January 2020 VA treatment note states that the Veteran's blood pressure was mildly elevated in the clinic, "likely due to pain." Although several VA medical opinions have been obtained throughout the course of this appeal, to date, no medical opinion has been obtained regarding the possible relationship between the Veteran's hypertension and her service-connected lumbar spine disability. On remand, an addendum opinion should be obtained. 3. Entitlement to service connection for a bilateral wrist disability. The Veteran seeks entitlement to service connection for a bilateral wrist disability. The Veteran claims she has bilateral wrist disorders as a result of her time in service while serving as a cook on a ship and that moving boxes and performing repetitive movements such as stirring large pots, slicing, and flipping food, caused her current disorder. Service personnel records confirm that her military occupational specialty was a mess management specialist, responsible for the preparation of meals, maintaining cleanliness and sanitation of pantry areas and officers' staterooms, and also served as an instructor for mess management specialist school. Medical records document several diagnoses, including right median neuropathy at the wrist, right ulnar neuropathy at the wrist, tendonitis of the bilateral wrists, and carpal and cubital tunnel of the bilateral upper extremities. Although the Veteran submitted private medical opinions that discussed her bilateral wrist disorders, no physician has specifically opined that her currently diagnosed bilateral wrist disorders were due to service. Of note, a November 2019 private opinion from Dr. W. opines that the Veteran's "condition is a direct result of her trauma sustained due to her military service." Importantly, however, in addition to noting the Veteran's various bilateral wrist diagnoses, the physician discussed multiple physical disorders in his assessment, and he failed to provide any further rationale for the opinion. A VA medical opinion was obtained in July 2019, at which time the examiner opined that the Veteran's bilateral wrist disorder was less likely than not caused by service. The examiner stated that the empiric evidence in the medical and occupational literature does not support a causative relationship between usual and customary work tasks associated with cooking and the Veteran's current musculoskeletal pathology; moreover, the mechanical loads and frequency of loads the Veteran would likely experience as a cook are well within a physiologic range and are unlikely to overload and overwhelm musculoskeletal tissue. Concluding, the examiner also noted that the Veteran's service record does not document objective findings consistent with a high energy injury to the soft tissues or osseous structures of the Veteran's wrists, such as fracture, internal derangement, tendon/ligament tear or dislocation. In the absence of such findings, a post traumatic or chronic inflammatory process is less likely than not. The VA examiner failed to provide an opinion regarding the several neurological diagnoses the Veteran has, however, and whether they are as likely as not caused by repetitive movements or moving heavy boxes during service as a cook. On remand, an addendum opinion should be obtained. The matters are REMANDED for the following action: 1. Obtain and associate all updated treatment records with the claims file. 2. Obtain an addendum VA medical opinion for the Veteran's hypertension. The claims folder must be reviewed by the examiner. The examiner should offer comments and an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability): * that the Veteran's current hypertension is proximately due to her service-connected lumbar spine disability; or, *that the Veteran's current hypertension is aggravated (beyond a natural progression) by her service-connected lumbar spine disability. If aggravation is found, please state to the extent possible the baseline severity of the hypertension before the onset of aggravation. The examiner should consider and discuss the following: a) the November 2019 private physician's opinion that the Veteran's chronic back pain exacerbates her hypertension; b) the January 2020 VA treatment note that indicates the Veteran's blood pressure was mildly elevated in the clinic, likely due to pain. All opinions must be supported by a clear rationale, and a discussion of the facts and medical principles involved. 3. Obtain an addendum opinion for the Veteran's claimed bilateral wrist disabilities. The claims folder must be reviewed by the examiner. For each diagnosed wrist disorder, particularly right median neuropathy at the wrist, right ulnar neuropathy at the wrist, and carpal and cubital tunnel of the bilateral upper extremities, the examiner should offer comments and an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) causally or etiologically due to service. The examiner should consider and discuss the Veteran's asserted theory that serving as a cook on a ship for 10 years, which required moving boxes and performing repetitive movements such as stirring large pots, slicing, and flipping food, caused her current disorders. All opinions must be supported by a clear rationale, and a discussion of the facts and medical principles involved. TANYA SMITH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. Andersen, 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.