free_spirit_etc

http://www.va.gov/vetapp08/files2/0813250.txt

Paul -- Your arguments should definitely not be near as long as the ones I am writing in here. I am just thinking them through and adding my reasoning. But in developing the arguments, you have to make sure you stay concise. After I wrote my argument to the BVA, I probably went over it 100 more times, polishing and fine-tuning, over and over again.

Allison.Hickey@va.gov

Paul, I don't know what your financial situation is, but I still think it would be great if you can get an IMO prior to the BVA hearing. You want your case to be strong enough to get SC granted, rather than a remand. A remand gives their doctors another shot at writing another unfavorable opinion. This an an article on Legg-Perthes -- http://www.orthoseek.com/articles/perthes.html I don't think this article is a good one to use for medical evidence. You would want some actual research studies -- but I am using it here for the information it contains. I have read the same information in various articles. "Statistically speaking, 60 to 70% of children with Perthes’ disease do well with no long term disability. With treatment, results are marginally better." " If the onset of the disease is before age 4, results tend to be good, with or without treatment. The older the child at the onset of disease, the less favorable the result." So it would seem that based on the early age of the onset of the disease, the fact that you did not require ongoing evaluation / care throughout childhood, etc. it does not seem like you would have been statistically likely to have ongoing problems (unless the condition was aggravated). The pain / limitation from your hips doesn't seem to be what would have been expected with the normal progression of your disease. If 60 to 70% of children do well with no long term disability (and the odds are even more favorable for those who have it before the age of 4) it seems like the "normal progression of your disease" should have resulted in no disability. Your IMO shouldn't have to prove that an high energy injury (such as a fracture or hip dislocation) "caused" the disability (as stated in the SOC). They should be able to show that based on sound medical principals your Legg's - Perthes condition should not have been expected to become disabling, especially at the time that it did, that it actually became disabling when you were in the military, and that it is more likely than not that something occurred while you were serving in the military to aggravate the condition.

The RO was in error to state that the February 5, 2004 report from XXXXX MD showed I had been treated in childhood for Legg-Perthes diease of the left hip, which in June 1999 resulted in minimal disability but a slight loss of left hip motion. The February 5, 2004 report specifically states, I was treated for a right knee injury (torn meniscus) in June 1999, but had not been seen or evaluate for the Legg-Perthes disease since I had received treatment from him for the condition as infant / youngster. Though Dr. XXX’s report stated that at the time he treated me for the Legg-Perthes condition (many years before as an infant / youngster) I had minimal disability and slight loss of motion in that (the left) hip, he did not state nor indicate that the minimal disability and slight loss of motion was permanent. He merely stated that I had a minimal disability and slight loss of motion at the time he treated me for the condition (as an infant / youngster). The Regional Office was in error to substitute their own medical judgement and state my Legg-Perthes disease was shown to be disabling in June 1999, when the doctor specifically stated I had not received treatment or evaluation for the left hip condition since I was an infant / youngster, and that he specifically treated me for a right knee injury (not a left hip disability) in June 1999. The RO was in error to state that the February 5, 2004 report from XXXXX MD showed I had been treated in childhood for Legg-Perthes diease of the left hip, which in June 1999 resulted in minimal disability but a slight loss of left hip motion. The February 5, 2004 report specifically states, I was treated for a right knee injury (torn meniscus) in June 1999, but had not been seen or evaluate for the Legg-Perthes disease since I had received treatment from him for the condition as infant / youngster. Though Dr. XXX’s report stated that at the time he treated me for the Legg-Perthes condition (many years before as an infant / youngster) I had minimal disability and slight loss of motion in that (the left) hip, he did not state nor indicate that the minimal disability and slight loss of motion was permanent. He merely stated that I had a minimal disability and slight loss of motion at the time he treated me for the condition (as an infant / youngster). The Regional Office was in error to substitute their own medical judgement and state my Legg-Perthes disease was shown to be disabling in June 1999, when the doctor specifically stated I had not received treatment or evaluation for the left hip condition since I was an infant / youngster, and that he specifically treated me for a right knee injury (not a left hip disability) in June 1999.

On the continuity of symptoms - When were you discharged? I am thinking your were discharged because they said the disability kept you from physically being unable to serve. When did you first seek treatment for the condition after service? What symptoms did you have between that time? I know that it is symptoms, not treatment, that establishes whether the condition is ongoing. But I was thinking there was a fairly short interval between the two (as compared to some of the cases at the BVA where they were discharged in the 50's, 60's, and 70's and now have degenerative disease in the hips.)

Paul, I apologize if I am asking questions that were already answered. I am currently experiencing shingles (ouch) and so between the pain and pain meds, my brain is not running on all of its cylinders. But I am trying to do what I can to help. Weren't you treated for the low back strain and hip strain in service at the same time? If so, it seems very odd that they gave you SC for the back strain, but denied SC for bilateral hip strain that occurred at the same time on the basis that ONE of your hips had a pre-existing condition - especially if the burden is on them to show by clear and unmistakable evidence that your hip condition was not aggravated by your service. It would also be interesting to see the reasoning they used to grant SC for the back strain. Some of the same reasoning might apply to the hips.

http://www.va.gov/vetapp15/Files1/1500522.txt This case was remanded, but here is some reasoning: "Initially, the Board notes that a Veteran is presumed in sound condition except for defects noted when examined and accepted for service. Noted denotes only such conditions that are recorded in examination reports. The existence of conditions prior to service reported by the Veteran as medical history does not constitute a notation of such conditions, but will be considered together with all other material evidence in determining the question of when a disease or disability began. 38 C.F.R. § 3.304(b)(1) (2014). Clear and unmistakable evidence that the disability existed prior to service and was not aggravated by service will rebut the presumption of soundness. Once the presumption of soundness has attached, VA holds the burden of proving by clear and unmistakable evidence that both (1) the Veteran's disease or injury pre-existed service, and (2) that the disease or injury was not aggravated by service. 38 U.S.C.A. § 1111 (West 2014). Clear and unmistakable evidence is a more formidable evidentiary burden than the preponderance of the evidence standard. Vanerson v. West, 12 Vet. App. 254 (1999) (clear and convincing burden of proof, while a higher standard than a preponderance of the evidence, is a lower burden to satisfy than clear and unmistakable evidence). It is an onerous evidentiary standard, requiring that the no-aggravation result be undebatable. Cotant v. West, 17 Vet. App. 116 (2003). Concerning clear and unmistakable evidence that the disease or injury was not aggravated by service, the second step necessary to rebut the presumption of soundness, a lack of aggravation may be shown by establishing that there was no increase in disability during service or that any increase in disability was due to the natural progress of the pre-existing condition. Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004); 38 U.S.C.A. § 1153 (West 2014)."

My husband's discharge physical was missing from his file. I wrote to the VA and told them that other veteran's records were in my husband's C-file - and asked them: 1. To please look in those veteran's files for my husband's missing records. 2. What they wanted me to do with the other veteran's records that were in my husband's file. They just gave me some blanket generic statement about how they had sent me everything in the file and that was all his records . They didn't really acknowledge that I had reported other veteran's confidential information being sent to me.

You might want to study some of the BVA claims for the same condition. http://www.index.va.gov/search/va/bva_search.jsp?QT=Perthes&EW=&AT=&ET=&RPP=10&DB=2015&DB=2014&DB=2013&DB=2012&DB=2011&DB=2010&DB=2009 Take note of the reasoning used on the claims that were both denied and granted. Your strength might be in them needing to show by clear and unmistakable evidence the condition was not aggravated in service more than you having to show that it was aggravated in service.

I agree the situation sucks. But I think you need to look in the other direction. If you were discharged from the service because of the disease, I don't see where showing the symptoms continued after discharge will strengthen your claim a lot. It seems like it is established the condition is currently present. It is established it was manifest in service. It is established it is the same condition. The contention is whether something in the service aggravated the pre-existing condition beyond the natural progression of the disease. Going years without needing treatment, and then pain in the service where you had to be discharged might be an area to look at.

I understand that. But my opinion still stands that your VA's doctor's statement is not particularly strong. It could help. Perhaps they would grant the claim. Perhaps it would be enough to get a remand, since the C&P doctor's opinion is also not strong -- especially if you can point out the C&P examiner overlooked specific information in your file that shows you did experience trauma in service. Perhaps the BVA will seek an outside opinion to decide the claim. If they want to, they could decide to not give much weight to your doctor's opinion because he directly points out he only viewed 2 pages of SMR documents on his original opinion, and two more documents on the addendum. The BVA could well say that he didn't form an opinion based on the entire medical record. He admits he only saw a few pages of your service medical records. I think your claim would be much stronger if you had an IMO that clearly stated it was based on the full medical record and it was more likely than not that the condition was aggravated by service. Your doctor's opinion states the SMR's showed you had back and hip pain in service. But I don't see where he refers to any injury or trauma. As you were discharged from the service because of the disease, I would think it is pretty clear that the disease was manifest in service and that you experienced pain. Their contention seems to be that it was a pre-existing condition that became disabling shortly after you entered the service with nothing to show there was a specific trauma or injury that should have made it disabling (if it was aggravated). I know it says you couldn't finish basic training and were discharged as the result of the disease. Can I ask how much of basic training you completed? I think what you have to overcome is how quickly it became disabling after entering the service from "non-specific" injuries. You say you were only treated for the disease at a very young age. Did you live a pretty typical life doing pretty typical things without pain? Were you in sports? Were you pretty active? If so - that should be in your favor. But I still think a stronger medical opinion with more solid rationale could help your claim. Of course, that is just my opinion. If you think your case is solid enough, then you can go with what you have. If you are asking for assistance in strengthening your claim - that is my opinion.

...dang

Old letters? Is there a possibility that you might have written to any friends / family and mentioned your neck hurting in any of the incidents? Or even after that? Couldn't jump school create situations that would impact someone's neck, even without documented injuries. When did you first receive treatment for your neck? The closer that was to your discharge, the better. You also might want to have someone else look over your medical records to see if the catch something you are missing.

A lot of this is over my head --at least at the moment. Berta, I am still struggling with how they can even order another medical opinion in your case. It seems like a fishing expedition to me.

I was interested in the VA home loan. A good thing about them is they have low down payments. But I was reading that they had higher interest and more fees than a conventional mortgage. So that is something to check out. But that is interesting information Berta. I didn't know they also gave loans for repairs and modifications.

I don't think the doctor's statement (from your doctor is particularly strong). He is saying he only saw two documents from your SMRs, and he gives very little rationale to back up his opinion. The VA wants the doctor to have access to your full medical record when rendering an opinion - and they want rationale for why he is issuing such an opinion. It looks like they are saying you did not meet the presumption of soundness because your condition was pre-existing and became manifest shortly after entry into the service. I didn't take the SSOC to be saying that your doctor said he treated you in 1999. I understood it to be saying that your doctor stated he had treated you in childhood, And it states in June 1999 your Perthe Disease resulted in minimal disability and slight loss of motion. They aren't saying the doctor said the part about 1999. They are saying your doctor treated you in childhood, and the condition he treated you for was shown to be minimally disabling in 1999. They are certainly acknowledging that you were discharged from service because of your Perthes disease. Their issue seems to be that the condition became manifest shortly after you entered the service.

That is interesting that he noted that you only had the disease in the left hip but you have decreased range of motion in both hips.

Here is a case for you http://www.va.gov/vetapp12/Files2/1209683.txt

So, your basic argument would be that it is a direct in-service injury, rather than an aggravated pre-existing condition.

That sounds interesting. You doctor could possibly strengthen his opinion by citing information that because of the young age of diagnosis, and the fact that you didn't have problems for years, it is not likely that you would have had hip problems in later life, unless the condition was aggravated in some way. http://www.mayoclinic.org/diseases-conditions/legg-calve-perthes-disease/basics/complications/con-20035572 In general, children who are diagnosed with Legg-Calve-Perthes after age 6 are more likely to develop hip problems later in life. The younger the child is, the better the chances for the hip joint healing in a normal, round shape. I think you need something stronger than just the doctor saying it is more likely than not. He will probably have to educate them a bit about Perthes.

So are you saying you were actually diagnosed with this as a child?

I agree with Asknod. Do you have copies of the letters your doctor wrote that you could post? Anything he could point out in the SMRs could help. Also, citing any medical research, studies, etc. that are applicable to your case could also strengthen it.

With the VA, nothing is absolute.

http://www.mayoclinic.org/diseases-conditions/legg-calve-perthes-disease/basics/lifestyle-home-remedies/con-20035572 Activity modification. Your child should avoid high-impact activities, such as running or jumping, because they can increase the amount of damage to the weakened bone and worsen symptoms.