BVA9501244 
DOCKET NO.  93-04 625     )       DATE
          )
          )
On appeal from the decision of the
Department of Veterans Affairs Regional Office in Jackson,
Mississippi

THE ISSUE

Entitlement to service connection for right hip, right knee, and
low back disorders, as secondary to a service-connected left knee
disability.

REPRESENTATION

Appellant represented by: Veterans of Foreign Wars of the
United States

WITNESS AT HEARING ON APPEAL

Appellant

ATTORNEY FOR THE BOARD

Joseph P. Gervasio, Jr., Counsel

INTRODUCTION

The veteran served on active duty from August 1941 to September
1945.

This case comes to the Board of Veterans' Appeals (Board) on
appeal of an April 1992 rating decision of the Jackson,
Mississippi, Regional Office (RO) of the Department of Veterans
Affairs (VA), which denied service connection for right hip,
right knee, and low back conditions, claimed as secondary to a
service-connected left knee disorder.

The case was remanded by the Board in August 1993 and returned in
February 1994.

CONTENTIONS OF APPELLANT ON APPEAL

The veteran contends that service connection should be granted
for right knee, right hip, and low back conditions because these
disorders were caused by his service-connected left knee
disability.  It is asserted that the veteran's physician has
rendered a medical opinion to this effect.

DECISION OF THE BOARD

The Board, in accordance with the provisions of 38 U.S.C.A.
§ 7104 (West 1991), has reviewed and considered all of the
evidence and material of record in the veteran's claims file.
Based on its review of the relevant evidence in this matter and
for the following reasons and bases, it is the decision of the
Board that the preponderance of the evidence is against the claim
for service connection for right hip, right knee, and low back
conditions secondary to a service-connected left knee disability.

FINDINGS OF FACT

1.  The veteran is service connected for a left knee disability,
postoperative residuals of a medial meniscectomy.

2.  Right knee, right hip, and low back disorders were not caused
by the service-connected left knee disability.

CONCLUSION OF LAW

The veteran's right knee, right hip, and low back disorders are
not proximately due to or the result of the service-connected
left knee disability.  38 C.F.R. § 3.310 (1993).

REASONS AND BASES FOR FINDINGS AND CONCLUSION

It is initially noted that the veteran's claim is well grounded;
that is, not inherently implausible.  38 U.S.C.A. § 5107(a).
Following the Board's remand, the relevant facts have been
developed to the extent possible, and the statutory obligation of
the VA to assist the veteran in the development of his claim has
been satisfied.  Id.

I.  Factual Background

The veteran's original claims file, which may have included his
service medical records, is not available.  Repeated efforts to
locate the file have not been successful.  His reconstructed
claims file shows that service connection is in effect for
cartilage removal of the left knee (postoperative medial
meniscectomy), rated as 10 percent disabling since at least 1984.

Medical records from Stephen L. Harless, M.D. (Family Practice
Clinic), show treatment for various conditions since 1988.  In
February 1988, the veteran was treated for arthritis of the neck
and shoulders.  In November 1990, the veteran complained of right
leg and hip pain for three months, and reported he stepped in a
hole and twisted his leg and hip.  On examination, the doctor
noted marked pain radiating to the left hip and left lower lumbar
spine.  X-rays of the lumbar spine, at Hattiesburg Clinic (on
referral from Dr. Harless) noted osteoporosis and degenerative
spurring consistent with the patient's age.  In December 1990,
the veteran was treated by Dr. Harless for peripheral vascular
disease and arthritis.  When seen in February 1991, the veteran
said that he was concerned that his leg arthritis stemmed from an
Army injury which required knee surgery; he said that since that
time his left leg had been smaller and shorter.  Current
impressions included peripheral vascular disease, status post leg
injury, and arthritis.  At an office visit in March 1991, it was
noted that the veteran mostly wanted to talk about service
connection and was fixated on thoughts of increasing service
connection.  Dr. Harless noted moderate organic brain syndrome.
Later in March 1991, the veteran complained of his hip and leg
hurting, and it was noted he was markedly compromised by organic
brain syndrome.  Dr. Harless indicated the veteran would be
referred to the VA.  A March 1991 X-ray report from Hattiesburg
Clinic (on referral from Dr. Harless) shows abnormalities of both
hips, more on the right side, with possible early changes of
ischemic necrosis.  At a subsequent March 1991 office visit to
Dr. Harless, the veteran reported he had gone to the VA, but was
still not satisfied.  Dr. Harless indicated he had an extended
discussion with the veteran concerning arthritis, peripheral
vascular disease, multiple systems problems, and his underlying
organic brain syndrome.  It was noted the veteran appeared to be
getting progressively more demented.

VA outpatient treatment records show that in March 1991, the
veteran gave a history of a left knee injury and operation in
service, and said he had noticed that his left leg appeared
shorter and he was now having right hip pain.  X-ray studies
showed early degenerative joint disease of the left knee and
sclerosis and flattening of the right femoral head.  Later in
March 1991, the veteran reported that after the service injury to
his left leg, he developed shortening of that limb and a limp,
and he said he now had right hip pain and weakness as well as low
back pain.  The impressions were questionable avascular necrosis
of the right hip and chronic anterior cruciate ligament
insufficiency of the left knee with leg length discrepancy.
Planned treatment included a left heel lift and left knee
rehabilitation.  A magnetic resonance imaging study (MRI) at
University Hospital in April 1991 showed aseptic necrosis of the
left hip, and changes of the femoral head of the right hip
consistent with advanced avascular necrosis or severe
degenerative joint disease.  VA outpatient records from June 1991
show continued complaints of left knee and right hip pain.
X-rays of the pelvis showed generalized osteoporosis.  When seen
in October 1991, the veteran continued to complain of left knee
and right hip pain; the impressions included chronic anterior
cruciate ligament insufficiency of the left knee, and avascular
necrosis of the femoral heads, the right greater than the left.

Medical records of Forest General Hospital and private doctors,
dated from 1984 to 1993, have been received.  These records show
that the veteran was treated for various disabilities, including
carcinoma of the rectum in August 1984, bronchitis in January
1988, a transurethral resection of the prostate in April 1988,
insertion of a penile prosthesis in February 1989, a right hip
replacement (performed by William Morrison, M.D.) for avascular
necrosis of the right hip in April 1992, a myocardial infarction
in March 1993, and low back pain in April 1993.  Diagnostic
studies in April 1993 showed slight scoliosis and associated
osteophyte formation of the lumbar spine, and an old compression
deformity of T12.  The veteran received subsequent outpatient
treatment for low back pain.

Medical records of M. R. O'Neal, M.D. (Family Practice Clinic),
show that in November 1991, the veteran requested a letter
stressing that his right hip condition was due to shortening of
the left leg.  The veteran told the doctor that he had prior
surgery on his left leg due to a service-connected injury, and
had subsequent atrophy and weakness of that leg.  On examination,
the right leg measured 97 centimeters in length and the left one
93 centimeters; calf circumference was 40 centimeters on the
right and 36 centimeters on the left; and a hip tilt and right
hip tenderness were noted.  Assessments included ischemic
necrosis of the right hip and left leg atrophy with shortening.
The doctor indicated that he would send a letter to the VA.  In a
November 1991 letter, Dr. O'Neal stated that he had examined the
veteran during 1991 for right hip pain and X-ray studies showed
early signs of ischemic necrosis of the right hip.  He noted that
the veteran gave a history of a previous service-connected injury
of the left leg, with subsequent vascular injury and subsequent
atrophy of the left leg.  The doctor stated that the veteran had
obvious hip tilt and definite asymmetry of leg lengths.  The left
leg measured 93 centimeters and the right leg measured
97 centimeters.  He stated that the veteran's right hip
deterioration could be considered contributed to if not caused by
weakness of the "right" leg, shortening of that leg, and
subsequent hip tilt.  A March 1992 office note from Dr. O'Neal
indicates that the veteran reported he had received a very
negative evaluation by the VA concerning right hip necrosis and
left leg atrophy and that the VA doctor had not found significant
shortening of his left leg.  Dr. O'Neal told the veteran that he
would not measure his legs and that a more appropriate evaluation
for that would be a radiographic measurement.  On a medical
consultation in April 1992, when the veteran was admitted to the
hospital for right hip replacement, Dr. O'Neal noted that he had
treated the veteran since November for recurrent right hip pain;
the veteran gave a history of suffering a left leg fracture
during World War II, with ischemic changes and atrophy of the
left leg; and the veteran said that he had been told by the VA
hospital that his hip problem was due to an abnormal weight and
gait causing gradual ischemic necrosis of the hip.

Additional medical records from Dr. Harless, dated in October
1992, show the veteran was treated for back pain with
radiculopathy, ischemic necrosis of the hip, arthritis, and
peripheral vascular insufficiency of the right leg.  The veteran
said he was having difficulty getting benefits from the VA and
would get Dr. O'Neal's records for Dr. Harless to review.  The
office notes of Dr. Harless mention that he subsequently sent a
letter to the VA at the veteran's request.  An October 1992
letter was received from Dr. Harless.  He stated that he had been
treating the veteran for several years, recently for progressive
back pain and radicular discomfort down the right leg.  The
doctor noted the veteran had avascular necrosis of the hip and
probably degenerative disc disease with radiculopathy.  He also
had marked peripheral vascular insufficiency.  Dr. Harless went
on to state that the veteran related his back injury and hip
problem to an injury received in service.  He recommended that
the veteran be reevaluated for questionable service-connected
disability.  Office notes from Dr. Harless from November 1992
indicate the veteran requested another letter, and such was
prepared.  In a November 1992 letter, Dr. Harless noted the
veteran had progressive deterioration of health due to
progressive ischemic necrosis of the right hip with pelvic tilt
(secondary to degenerative changes in his leg, hip and spine),
chronic pain syndrome, and organic brain syndrome.  It was noted
that right leg length had been measured at about 97 centimeters
and left leg length was about 93 centimeters.  A September 1993
office record of Dr. Harless shows impressions of insomnia,
confusion, organic brain syndrome and arthritis.

An orthopedic examination was conducted by the VA in March 1992.
The 77-year-old veteran gave a history of being service connected
for left knee cartilage removal, and having problems with that
leg over the years.  He said that the condition was progressively
worsening and that he had left knee pain and locking and
shortening of the left leg.  The veteran also reported problems,
over the last year or so, with his back, right hip and right
knee.  He presented a letter from his private doctor, noting 1991
X-ray evidence of early ischemic necrosis of the right hip.
Current VA X-rays showed avascular necrosis of the right hip,
minimal narrowing of the medial joint compartments of both knees,
and mild narrowing of the L5 - S1 interspace and anterior spur
formation at L3 and L5 in the low back.  On clinical examination,
it was noted that the veteran walked with a slow gait pattern and
mild limp.  The back showed no spasm or tenderness; the veteran
could stand erect and had some reduced range of motion.  There
was pain on extremes of motion of the right hip.  Both knees had
full range of motion, mild generalized tenderness to palpation,
no heat or swelling, and no definite instability.  A well-healed
surgical scar was noted on the medial aspect of the left knee.
The examiner was unable to measure more than 1 centimeter
difference in lower extremity limb lengths, with the left being
slightly shorter.  There was increased pigmentation of both lower
extremities compatible with early stasis changes.  The
impressions were postoperative medial meniscectomy of the left
knee, overuse syndrome of the right knee, early avascular
necrosis of the right hip, and recurrent low back pain.  The
examiner stated that the conditions of the back, right hip and
right knee were not directly caused by the service-connected left
knee condition, but the presence of the left knee condition
probably exacerbated the problems in the other areas.

A hearing was conducted before a member of the Board at the RO in
February 1993.  The veteran related the circumstances surrounding
the injury of his left knee and subsequent treatment that he had
during service.  He said that after service he worked at various
construction jobs but had retired.  He stated he had no
additional left knee operations after service.  The veteran
essentially argued that the service-connected left knee condition
resulted in shortening of the left leg, which in turn put undue
stress on other areas and caused a right hip, right knee, and low
back disorder.  He said he had been receiving treatment for the
additional problems for about two years.

II.  Analysis

There is no evidence in the record that the right hip, right
knee, and low back conditions were sustained during service, nor
does the veteran contend otherwise.  Rather, the veteran claims
secondary service connection, asserting that a favoring of his
left knee, due to service-connected disability of that joint, led
to the development of disability in other areas.

Secondary service connection may be granted for disability which
is proximately due to or the result of a service-connected
disease or injury.  38 C.F.R. § 3.310(a).

The veteran has submitted statements from two physicians in
support of his claim for secondary service connection.  The
statements of Dr. Harless, however, do not contain a medical
opinion that the right hip, right knee and low back conditions
were caused by the service-connected left knee condition.
Rather, he essentially stated that the veteran related that there
was such a relationship and suggested that the question of
service connection be explored.  This does not have probative
value concerning the issue at hand.

The statement submitted by Dr. O'Neal is more supportive of the
veteran's contentions.  He believed that the condition of the
veteran's left leg could have caused or contributed to the
veteran's right hip condition.  However, close review of the
record indicates that Dr. O'Neal's opinion is largely based on an
erroneous factual premise concerning the nature of the
service-connected disability, and thus, the opinion has little or
no probative value.  Reonal v. Brown, 5 Vet.App. 458 (1993).

In this regard, the veteran is service connected only for
postoperative residuals of removal of the medial meniscus
cartilage of the left knee.  The veteran told Dr. O'Neal (and
other doctors) that his service-connected condition involved a
leg fracture or other serious injury, followed by ischemic
changes and atrophy of the left leg; but there is no credible
evidence to support this.  There is no indication of any
significant long-term complications from the removal of the left
knee cartilage in service.  In fact, the 1992 VA examination
disclosed only minimal abnormal findings with regard to the
service-connected left knee condition and, with the exception of
the well-healed meniscectomy scar, the left knee was about the
same as the right one.  No significant left leg shortening was
noted on the 1992 VA examination and, although Dr. O'Neal had
earlier found somewhat greater shortening of the limb, there is
nothing in the record to suggest that the leg shortening, even if
it exists, could be due to the left knee meniscectomy.

The chronological treatment records indicate that the theory of
secondary service connection (essentially, that the
service-connected condition involved a major left leg injury with
severe residual symptoms, a gait disturbance, and undue strain on
the other body areas) originated with the veteran himself, who
presented the story to the private and VA doctors.  However,
inasmuch as there is no credible evidence to support the history
recited by the veteran, the subsequent supportive medical
opinions based on the history are discredited.

The veteran was examined by the VA in March 1992.  The VA
physician who examined him was aware of the true nature and
extent of the service-connected left knee condition.  The doctor
opined that the left knee condition did not directly cause the
right knee, right hip, and low back conditions, but that these
latter conditions were probably exacerbated by the left knee
disability.  This is probative evidence against secondary service
connection.  Secondary service connection requires proximate
causation and is not warranted where a service-connected disorder
merely aggravates, or causes an additional increment to, another
existing condition.  Leopoldo v. Brown, 4 Vet.App. 216 (1993).

Other evidence of record contains no medical opinion supporting a
proximal causal relationship between the service-connected left
knee disorder and the right knee, right hip, and low back
conditions.  The veteran himself opines that there is such a
relationship, but, being a layman, he has no competence to offer
an opinion on medical causation.  Espiritu v. Derwinski,
2 Vet.App. 492 (1992).

The weight of the evidence of record establishes that right knee,
right hip, and low back conditions began long after service and
are not proximately due to or the result of the service-connected
left knee condition.  As the preponderance of the evidence is
against the claim, the benefit of the doubt doctrine, 38 U.S.C.A.
§ 5107(b), is inapplicable, and secondary service connection must
be denied.  Gilbert v. Derwinski, 1 Vet.App. 49 (1990).

ORDER

Service connection for right knee, right hip, and low back
conditions, as secondary to a service-connected left knee
disorder, is denied.

          L. W. TOBIN
          Member, Board of Veterans' Appeals

The Board of Veterans' Appeals Administrative Procedures
Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___
(1994), permits a proceeding instituted before the Board to be
assigned to an individual member of the Board for a
determination.  This proceeding has been assigned to an
individual member of the Board.

NOTICE OF APPELLATE RIGHTS:  Under 38 U.S.C.A. § 7266 (West
1991), a decision of the Board of Veterans' Appeals granting less
than the complete benefit, or benefits, sought on appeal is
appealable to the United States Court of Veterans Appeals within
120 days from the date of mailing of notice of the decision,
provided that a Notice of Disagreement concerning an issue which
was before the Board was filed with the agency of original
jurisdiction on or after November 18, 1988.  Veterans' Judicial
Review Act, Pub. L. No. 100-687, § 402 (1988).  The date which
appears on the face of this decision constitutes the date of
mailing and the copy of this decision which you have received is
your notice of the action taken on your appeal by the Board of
Veterans' Appeals.