Citation Nr: 18154183
Decision Date: 11/29/18	Archive Date: 11/29/18

DOCKET NO. 16-40 290
DATE:	November 29, 2018
ORDER
1.  Entitlement to a disability rating in excess of 10 percent for postoperative left hip bursitis is denied.  
2.  The application to reopen entitlement to service connection for a low back disability, to include as due to service-connected postoperative left hip bursitis, is denied.  
3.  Entitlement to service connection for fibromyalgia, to include as due to service-connected postoperative left hip bursitis, and to include as due to contaminated water at Fort McClellan, Alabama, is denied.   
4.  Entitlement to service connection for mixed connective tissue disease, to include as due to contaminated water at Fort McClellan, is denied. 
REMANDED
5.  Entitlement to service connection for a right hip strain, to include as due to service-connected postoperative left hip bursitis, is remanded.  
FINDINGS OF FACT
1.  The Veteran’s left hip bursitis disability has not manifested with limited range of motion in flexion of the left thigh to 30 degrees or less during the appeal.  
2.  In a December 2004 decision, the Board denied the issue of entitlement to service connection for a low back disability, to include as secondary to service-connected left hip bursitis.  Although notified of the Board’s decision by a December 2004 letter, the Veteran did not appeal this decision, and the decision became final.  
3.  Evidence associated with the claims file since the December 2004 Board decision, when considered by itself or in connection with evidence previously assembled, does not relate to an unestablished fact necessary to substantiate the claim of entitlement to service connection for a low back disability, and does not raise a reasonable possibility of substantiating the claim.
4.  The Veteran did not incur an event, injury, or disease related to her current fibromyalgia during active duty service, and this disorder is not caused or aggravated by her service-connected postoperative left hip bursitis.  
5.  The Veteran did not incur an event, injury, or disease related to her current mixed connective tissue disease during active duty service, to include being stationed at Fort McClellan.
CONCLUSIONS OF LAW
1.  The criteria for a disability rating in excess of 10 percent for postoperative left hip bursitis have not been met.  38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5019-5252 (2017).
2.  The December 2004 Board decision denying the claim of entitlement to service connection for a low back disability, to include as secondary to service-connected left hip bursitis, is final.  38 U.S.C. § 7104(b) (2012); 38 C.F.R. § 20.1100 (2017).
3.  As evidence received since the December 2004 Board decision is not new and material, the criteria for reopening the claim of entitlement to service connection for a low back disability, to include as due to service-connected postoperative left hip bursitis, have not been met.  38 U.S.C. §§ 5108, 7104 (2012); 38 C.F.R. § 3.156 (2017).
4.  The criteria for entitlement to service connection for fibromyalgia, to include as due to service-connected postoperative left hip bursitis, and to include as due to contaminated water at Fort McClellan, have not been met.  38 U.S.C. §§ 1110, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.303, 3.304, 3.310 (2017).
5.  The criteria for entitlement to service connection for mixed connective tissue disease, to include as due to contaminated water at Fort McClellan, have not been met.  38 U.S.C. §§ 1101, 1131, 5107(b); 38 C.F.R. §§ 3.303, 3.304.
REASONS AND BASES FOR FINDINGS AND CONCLUSIONS
The Veteran had active duty service from January 1981 to September 1981 and from October 1981 to October 1984. 
VA’s duty to assist includes providing a medical examination and/or obtaining a medical opinion when necessary to make a decision on a claim, as defined by law.  See 38 U.S.C. § 5103A (2012); 38 C.F.R. §§ 3.159(c)(4), 3.326(a) (2017); see also McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006).  The Veteran has not been provided with a VA examination for her service connection claim for mixed connective tissue disease.  However, as explained below, the Board finds that there was no event, injury, or disease related to the Veteran’s current mixed connective tissue disease that occurred in service, which is one of the criteria needed for entitlement to a VA examination.  McLendon, 20 Vet. App. at 81; see 38 U.S.C. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i).  VA, therefore, has no duty to provide a medical examination for this claim.
1.  Increased Rating for Postoperative Left Hip Bursitis 
The Veteran contends that her service-connected left hip bursitis disability should be rated higher than the currently-assigned 10 percent disability rating.  
VA has adopted a Schedule for Rating Disabilities (Schedule) to evaluate service-connected disabilities.  See 38 U.S.C. § 1155; 38 C.F.R., Part IV.  Disability evaluations assess the ability of the body as a whole, the psyche, or a body system or organ to function under the ordinary conditions of daily life, to include employment.  38 C.F.R. § 4.10.  The percentage ratings in the Schedule represent the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations.  38 U.S.C. § 1155; 38 C.F.R. § 4.1.  The percentage ratings are generally adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the disability.  Id.
In disability rating cases, VA assesses the level of disability from the initial grant of service connection or a year prior to the date of application for an increased rating and determines whether the level of disability warrants the assignment of different disability ratings at different times over the course of the claim, a practice known as “staged ratings.”  The record shows that the appeal period for the left hip disability stems from November 15, 2013. 
Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance.  It is essential that the examination on which ratings are based adequately portray the anatomical damage and the functional loss with respect to all these elements.  The functional loss may be due to absence of part, or all, of the necessary bones, joints, and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 
The provisions of 38 C.F.R. § 4.40 allow for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements.  Under 38 C.F.R. § 4.45, functional loss due to weakened movement, excess fatigability, and incoordination must also be considered.  See DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995).  
Furthermore, 38 C.F.R. § 4.59 recognizes that painful motion is an important factor of disability.  Joints that are painful, unstable, or misaligned, due to healed injury, are entitled to at least the minimum compensable rating for the joint.  Id.  Special note should be taken of objective indications of pain on pressure or manipulation, muscle spasm, crepitation, and active and passive range of motion of both the damaged joint and the opposite undamaged joint.  Id.; see Burton v. Shinseki, 25 Vet. App. 1 (2011).  Pain that does not result in additional functional loss does not warrant a higher rating.  See Mitchell v. Shinseki, 25 Vet. App. 32, 42-43 (2011).
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.  When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the Veteran.  38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3 (2017). 
In deciding claims, it is the Board’s responsibility to evaluate the entire record on appeal.  See 38 U.S.C. § 7104(a) (2012).  Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss each and every piece of evidence submitted by the Veteran or on her behalf.  See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000).  Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims.  See Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000).
The Veteran contends that her postoperative left hip bursitis should be rated higher than the currently-assigned 10 percent disability rating.  Her left hip disability is rated under 38 C.F.R. § 4.71a, DC 5019-5252, which rates limitation of flexion of the thigh.  DC 5252 assigns a 10 percent rating for flexion limited to 45 degrees; a 20 percent rating for flexion limited to 30 degrees; a 30 percent rating for flexion limited to 20 degrees; and, a 40 percent rating for flexion limited to 10 degrees. 
Normal range of motion for the hip is flexion from zero to 125 degrees and abduction from zero to 45 degrees.  38 C.F.R. § 4.71, Plate II (2017).
The record shows that the Veteran filed an increased rating claim for the left hip in November 2013.  
In a March 2014 statement, she contended that she favored her left hip for quite some time, and that this disability aggravated her low back and right hip disorders.  
In a May 2014 VA general inquiry note, the Veteran reported to a medical professional that she had pain in the back of her left leg since January 2014.  
A June 2014 VA examination report showed that the Veteran complained of constant left hip pain, and that she had shooting pains down her legs.  She reported that she had bursa removed from the left hip in 1986, and that this was the only surgery she had for this hip.  She reported flare-ups once every one-to-two weeks and that flare-ups occurred depending on her activities.  Initial range of motion testing showed left hip flexion to 60 degrees with pain noted at 60 degrees, and left hip extension to greater than 5 degrees with no objective evidence of painful motion during extension.  The examiner noted that abduction was not lost beyond 10 degrees, and that abduction was not limited such that the Veteran could not cross her legs.  Rotation was not limited such that the Veteran could not toe-out more than 15 degrees.  Same results were noted after repetitive use testing, and the Veteran was noted to not have any additional limitation in range of motion of the hip and thigh after three repetitions.  However, she had less movement than normal and pain on movement.  The examiner noted that the Veteran had localized tenderness or pain to palpation to the left hip, but her muscle strength testing showed normal results.  The examiner noted that the Veteran did not have ankylosis in either hip joint.  The examiner noted that the Veteran regularly used a cane to help with ambulation.  
An x-ray report showed that the left hip was normal and that there was no documented degenerative or traumatic arthritis noted.  The examiner noted that the Veteran’s bilateral hip symptoms impacted her ability to work, but that she had retired in 1995.  The examiner noted that the Veteran’s complaints on range of motion testing were not consistent with other normal examination findings or the fact that the Veteran had a normal x-ray of the hips.  The examiner determined that it seemed probable that the Veteran did not give the maximum effort during the examination considering that she was sitting at a 90-degree angle when in a chair, but was only able to move to 50 degrees in the right leg during range of motion testing.  
In an August 2014 statement, the Veteran contended that she was not evaluated for left hip flexion during the previous VA examination.  She stated that she had to walk with a cane on most days, but that she could “limp along without it” on good days.  She again noted that she favored her left hip and that she had pain in this area.  
Similarly, in a June 2015 notice of disagreement (NOD), the Veteran contended that she was unable to flex the left hip or thigh laterally more than a couple of degrees.  She stated that raising her left knee to her chest was only possible a few degrees, and that she was unable to extend her left leg from the knee without considerable muscle cramping in her thigh.  She contended that she was unable to stand more than 10 minutes or walk for more than 10-to-15 minutes without needing to sit down and that she was unable to sit more than an hour.  She stated that she had to stop very frequently during road trips to stretch.  She reported that she used a cane when leaving her home, but that she did not use the cane around the house.  She reported that she had fallen several times, even with the use of a cane. 
In an August 2016 statement associated with her substantive appeal to the Board (VA Form 9), the Veteran contended that she had tried every prescribed and over-the-counter medication for pain since separating from active duty service.  She also stated that although many doctors have noted that she had a normal gait, it was not a normal gait for her.  
Likewise, in a December 2017 statement, she asserted that she had degeneration in both hips due to her altered gait.  
Given this evidence, the Board finds that the Veteran’s left hip bursitis disability has not manifested with limited range of motion in flexion of the left thigh to 30 degrees or less during the appeal.  Specifically, while the Veteran complained of left hip pain throughout the appeal, and was noted to have limited range of motion and to have to use a cane, including in May 2014, August 2014, August 2016, and December 2017 statements, the record does not show that her left thigh was limited in flexion to 30 degrees or less.  In fact, the June 2014 VA examination showed that she was able to flex the left thigh to 60 degrees with pain, and that there was no limitation with extension or painful motion in extension of the left thigh.  While the Board has considered the Veteran’s assertions in the June 2015 NOD that she was only able to lift her left knee to her chest to a few degrees and that she was unable to extend her left leg from the knee without considerable muscle cramping in her thigh, the clinical findings established during the June 2014 VA examination show that her initial and repetitive-use range of motion was limited to 60 degrees in flexion of the left thigh with pain.  
The Board has considered whether a higher rating should be assigned pursuant to 38 C.F.R. §§ 4.40, 4.45, 4.59, DeLuca, and Mitchell criteria but determines that a higher rating is not warranted for the Veteran’s disability picture.  The range of motion testing conducted during the medical evaluation considered the thresholds at which pain limited motion.  The Veteran reported having flare-ups of her symptoms during the June 2014 VA examination and the medical examination showed the presence of any additional functional impairment due to such symptoms as pain, pain on repeated use, fatigue, weakness, lack of endurance, and incoordination.  However, even though there is evidence of reduced flexion, and even after considering the effects of pain and functional loss, the evidence does not show that the Veteran’s left hip bursitis disability resulted in limited range of motion in flexion of the left thigh or the functional equivalent to 30 degrees or less at any time during the appeal.  Thus, a higher rating under these provisions is not approximated in the Veteran’s disability picture.
Accordingly, as the preponderance of the evidence is against a disability rating in excess of 10 percent for postoperative left hip bursitis, the benefit-of-the-doubt rule does not apply, and the Veteran’s claim must be denied.  See 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.71a, DCs 5019-5252; Gilbert v. Derwinski, 1 Vet. App. 49 (1990).
2.  Application to Reopen Entitlement to Service Connection for a Low Back Disability 
In November 2013, the Veteran submitted an application to reopen entitlement to service connection for a low back disability.   
VA may reopen and review a claim that has been previously denied if new and material evidence is submitted by or on behalf of a veteran.  38 U.S.C. § 5108; 38 C.F.R. § 3.156(a); see Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998). 
VA defines “new” evidence as evidence not previously submitted to agency decision makers and “material” evidence as evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim.  New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim.  38 C.F.R. § 3.156(a). 
The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is “low.”  See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010).  In determining whether this low threshold is met, VA should not limit its consideration to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the VA Secretary’s duty to assist or through consideration of an alternative theory of entitlement.  Id. at 118.
When determining whether the claim should be reopened, the credibility of the newly submitted evidence is presumed.  See Justus v. Principi, 3 Vet. App. 510 (1992).  The newly presented evidence need not be probative of all the elements required to award the claim, just probative of each element (or at least one element) that was a specified basis for the last disallowance of the claim.  See Evans v. Brown, 9 Vet. App. 273, 283 (1996).
In the December 2004 decision, the Board denied the claim of entitlement to service connection for a low back disability, to include as secondary to service-connected left hip bursitis, because the Veteran’s low back disability, including osteoarthritis, was initially demonstrated years after service, and the record did not include a competent clinical opinion linking the current low back disability to the Veteran’s active duty service.  Additionally, while the Board noted the Veteran’s lay assertions, including in her January 2004 Board hearing testimony, that her service-connected left hip bursitis caused an altered gait, which caused her low back disability, the Board determined that the medical evidence of record did not establish that the Veteran’s low back disability was caused or aggravated by her service-connected left hip bursitis.  In support of its finding, the Board determined that the March 2002 VA examiner’s findings and opinions that the Veteran’s low back complaints were not due to any limping or abnormal use of the left hip, but were rather due to something other than the left hip disability, were more probative than the Veteran’s lay statements regarding the causal connection between the left hip bursitis and low back disability.   
The Veteran was notified of the Board’s denial by a December 2004 letter, which included a “Your Rights to Appeal Our Decision” attachment and explained to the Veteran how to appeal the Board’s decision to the U.S. Court of Appeals for Veterans Claims.  The Veteran did not appeal the Board decision.  Thus, the December 2004 Board decision is final as to the evidence then of record, and is not subject to revision on the same factual basis.  See 38 U.S.C. § 7104(b); see also 38 C.F.R. §§ 3.156(a), 20.1100.  
Since the December 2004 Board decision, the Veteran has submitted additional lay statements alleging that her current low back disability was caused or aggravated by her service-connected postoperative left hip bursitis.  She made such contentions in March 2014, July 2014, August 2014, June 2015, August 2016, and December 2017 statements, as well as January 2013, May 2014, and May 2016 VA general inquiry notes, in which she alleged that her altered gait from the service-connected left hip disability caused her low back disorder.  Additional VA and private treatment records since the December 2004 Board decision, including from October 2017 and December 2017, show the presence of a current low back disability; however, these medical records do not discuss the causal relationship between the Veteran’s current low back disability and her active duty service or her service-connected postoperative left hip bursitis.   
Evidence associated with the claims file since the December 2004 Board decision, when considered by itself or in connection with evidence previously assembled, does not relate to an unestablished fact necessary to substantiate the claim of entitlement to service connection for a low back disability and does not raise a reasonable possibility of substantiating the claim.  Specifically, the Veteran’s lay statements from January 2013, March 2014, May 2014, July 2014, August 2014, June 2015, May 2016, August 2016, and December 2017 that her current low back disability was caused or aggravated by her service-connected left hip bursitis are cumulative or redundant to those statements she made to VA prior to the December 2004 Board decision.  Thus, these assertions were known to VA adjudicators when the claim for service connection was denied in December 2004.  The remainder of the new evidence in the form of VA and private treatment records since December 2004 pertain to the presence of a current low back disability, which was known to VA adjudicators prior to the issuance of the December 2004 Board decision.  However, these new treatment records do not discuss or establish a causal link between the current low back disability and the Veteran’s active duty service or service-connected left hip disability.    
Overall, the new lay and medical evidence does not raise a reasonable possibility of substantiating the claim because the new evidence does not show a causal link between the low back disability and the Veteran’s active duty service or service-connected postoperative left hip bursitis.  Accordingly, the application to reopen the claim of entitlement to service connection for a low back disability, to include as due to service-connected postoperative left hip bursitis, is denied.  38 U.S.C. § 5108; 38 C.F.R. § 3.156.
3. – 4.  Entitlement to Service Connection for Fibromyalgia and Mixed Connective Tissue Disease 
The Veteran contends that her fibromyalgia was caused by her active duty service, to include being exposed to contaminated water while stationed at Fort McClellan, and/or caused or aggravated by her service-connected left hip bursitis.  She also contends that her mixed connective tissue disease was caused by her active duty service, to include being exposed to contaminated water while stationed at Fort McClellan.  Because the evidence pertaining to these disorders is located in the same or similar documents, the Board shall analyze them together below.  
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).  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.  Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010).  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 also be granted for a disability that is proximately due to or the result of a service-connected disease or injury.  38 C.F.R. § 3.310(a).  When service connection is established for a secondary disability, the secondary disability shall be considered a part of the original disability.  Id.  Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability.  Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc).
Initially, the Board notes that the Veteran has current diagnoses of fibromyalgia and mixed connective tissue disease.  For example, she was diagnosed with fibromyalgia during an August 2015 VA examination.  She was also diagnosed with fibromyalgia and mixed connective tissue disease in a July 2009 VA rheumatology note.  Thus, the first element of service connection is met.  
However, the Board finds that the Veteran did not incur an event, injury, or disease related to her current diagnoses of fibromyalgia and mixed connective tissue disease during active duty service, to include being exposed to contaminated water while stationed at Fort McClellan.  Specifically, her service treatment records do not show complaints of or treatment for these disorders during active duty service.  For example, the Veteran’s January 1981 and October 1981 service enlistment reports of medical examination, did not show any such symptoms or complaints.  Likewise, the remainder of the Veteran’s service treatment records do not show any diagnosis, treatment, or complaints of fibromyalgia or mixed connective tissue disease.  In fact, the record indicates that the Veteran was first diagnosed with these disorders in July 2004, or approximately 19 years after separation from active duty service.  
The Board acknowledges the Veteran’s statements in her September 2015 NOD and August 2016 VA Form 9, as well as those statements from her representative in June 2015 and May 2018, contending that her current fibromyalgia and mixed connective tissue disease were caused by her exposure to polychlorinated biphenyls (PCBs) while stationed at Fort McClellan.  Specifically, she asserted in these statements that these disorders were caused by genetic mutations caused by PCB contamination from chemical exposure while she was stationed at Fort McClellan.  In support of her contentions, she submitted a September 2014 Internet article discussing in general terms the presence of PCBs, radioactive compounds, and chemicals at Fort McClellan and their impact on soldiers’ health.  However, this article did not discuss the Veteran’s asserted exposure to such chemicals and compounds or her medical and service history.  
The record shows that the Veteran was stationed at Fort McClellan during her active duty service.  However, while VA has noted that potential exposures during service at that location could have included radioactive compounds, chemical warfare agents, and airborne PCBs, VA has determined that there are currently no adverse health conditions associated with service at Fort McClellan.  See https://www.publichealth.va.gov/exposures/fort-mcclellan/.  Additionally, presumptive service connection has not been established for exposure to chemicals at Fort McClellan.  
Moreover, while the Veteran and her representative are competent to report symptoms that they perceive through their own senses, they are not competent to offer an opinion as to the cause of the Veteran’s fibromyalgia and mixed connective tissue disease due to the medical complexity of the matters involved.  These disorders require specialized training for determinations as to diagnosis, causation, and progression, and are therefore not susceptible to lay opinions on diagnosis, causation, or aggravation.  Thus, the Veteran and her representative are not competent to render opinions or attempt to present lay assertions to establish the cause of these disorders.  
Overall, the preponderance of the evidence is against a finding that the Veteran incurred an event, injury, or disease related to her current diagnoses of fibromyalgia and mixed connective tissue disease during active duty service.  The Board’s findings are buttressed by the fact that VA has determined that there are currently no adverse health conditions associated with service at Fort McClellan, that the Veteran was first diagnosed with these disorders in 2004, or approximately 19 years after separation from active duty, and that no medical professional has attributed these diagnoses to the Veteran’s periods of service.  See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006).
The Veteran also contends that her fibromyalgia was caused or aggravated by her service-connected postoperative left hip bursitis disability.  Specifically, in an August 2014 statement, she contended that her left hip disability worsened her fibromyalgia.  In this regard, she was afforded a VA examination in August 2015, during which the examiner confirmed her diagnosis of fibromyalgia.  After performing a physical examination, noting the Veteran’s self-reported history and symptoms, and reviewing the pertinent records, the examiner determined that the Veteran’s fibromyalgia was not proximately due to her service-connected left hip bursitis.  The examiner noted that medical literature was unclear regarding risks for or causative factors for fibromyalgia, but studies indicated possible connections to a host of factors, which include a genetic basis, serotonin genes, altered pain arousal processes, a general hyper arousal state, hyperactive stress syndrome, abnormal function of autonomic nervous system, immune system changes, and abnormal peripheral pain mechanisms.  The examiner further explained that there was no mention in the medical literature reviewed of a single joint or unilateral joint pain as a causative factor for fibromyalgia.  The examiner stated that she was unable to connect the Veteran’s fibromyalgia diagnosis in 2009 with her left hip bursitis, which was diagnosed in 1984, or approximately 24 years earlier.  
The August 2015 VA examiner’s opinions, which are competent on the issue of causation of medically complicated matters, are highly probative as to the causal link between the Veteran’s fibromyalgia and her service-connected left hip bursitis because of the examiner’s expertise, training, education, proper support and explanations, and thorough review of the Veteran’s records and self-reported symptoms.  Accordingly, the Board finds that the Veteran’s current fibromyalgia is not caused or aggravated by her service-connected postoperative left hip bursitis.  
Therefore, as the preponderance of the evidence is against entitlement to service connection for fibromyalgia and mixed connective tissue disease, the benefit of the doubt doctrine does not apply, and the Veteran’s claims must be denied.  38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 49. 
REASONS FOR REMAND
The Board must remand the claim of entitlement to service connection for a right hip strain, to include as due to service-connected postoperative left hip bursitis, for an addendum VA medical opinion.  Specifically, while the Veteran underwent a VA examination for the bilateral hips in June 2014, the Board determines that the medical opinion garnered during the examination regarding the cause of the Veteran’s right hip strain is inadequate.  See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007).  Specifically, although the examiner noted that the Veteran’s right hip strain was at least as likely as not (50 percent or greater probability) incurred in or caused by the claimed in-service injury, event, or illness, the examiner did not provide any discussion regarding the causal connection between the Veteran’s right hip strain and her active duty service.  The Board notes that the Veteran is not contending, nor does the record suggest, that her right hip strain was caused by or otherwise related to her active duty service.  Rather, she contends that it is caused or aggravated by her service-connected left hip bursitis.  In this regard, the June 2014 VA examiner determined that the Veteran’s left hip bursitis did not cause her right hip disorder; however, the examiner did not provide an opinion as to whether the service-connected left hip bursitis disability aggravated the Veteran’s right hip strain.  Thus, on remand, the June 2014 VA examiner should provide an addendum VA medical opinion.  
The matter is REMANDED for the following action:
Return the claims file to the June 2014 VA examiner who examined the Veteran’s right hip disorder, and request that she re-review the claims file and respond to the below inquiries regarding the Veteran’s service connection claim for right hip strain.  If that examiner deems it necessary or is otherwise unavailable, schedule the Veteran for an appropriate VA examination to assist in determining the nature and cause of her current right hip disorder symptoms.  All appropriate tests, studies, and consultations should be accomplished and all clinical findings should be reported in detail. 
Based upon a review of the relevant evidence, history provided by the Veteran, the June 2014 VA examination report, and sound medical principles, the VA examiner should provide an opinion as to:
(a.) Whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s current right hip strain was caused by the service-connected left hip bursitis. 
(b.) If the answer to (a.) is no, is it at least as likely as not that the Veteran’s right hip strain was permanently aggravated beyond the natural progression by the service-connected left hip bursitis?
(c.) If the examiner finds that the service-connected left hip bursitis aggravates/aggravated the Veteran’s right hip strain, the examiner is asked to state whether there is medical evidence created prior to the aggravation or at any time between the time of aggravation and the current level of disability that shows a baseline for the right hip strain prior to aggravation.  If the examiner is unable to establish a baseline for the right hip strain prior to the aggravation, he or she should state such and explain why a baseline cannot be determined.
The examiner is asked to provide a rationale with reference to relevant evidence of record and/or medical principles, as appropriate, for all conclusions reached.  If the examiner is unable to provide an opinion without resorting to speculation, he or she should explain why this is so and what if any additional evidence would be necessary before an opinion could be rendered. 

 
A. P. SIMPSON
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	A. Hodzic, Counsel 

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