Citation Nr: 0810010 Decision Date: 03/26/08 Archive Date: 04/09/08 DOCKET NO. 06-28 656 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUE Entitlement to service connection for a disability manifested by pain and numbness of the right hip and leg. WITNESS AT HEARING ON APPEAL The veteran ATTORNEY FOR THE BOARD R. Kessel, Associate Counsel REMAND The veteran had active military service from June 1975 to September 1975. This matter comes before the Board of Veterans' Appeals (Board) on appeal from December 2005 and April 2006 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. Service connection may be established for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2007). The veteran asserts that he has a disability manifested by right hip and right leg pain. He states that he first suffered an injury to the area during basic military training. The veteran believes the current disability is related to the in-service injury; thus, he contends that service connection is warranted. A review of the veteran's service medical records does not reveal any information regarding the right hip or right leg. The records show that the veteran was treated for asthma and medically discharged as a result of that disability. Nevertheless, the veteran contends that he also injured his right hip and right leg. In February 2008, the veteran testified at a hearing before the Board. He stated that he participated in basic military training in Camp Pendleton, California. While he was climbing a mountain during training, a fellow trainee fell down in front of him. Several trainees were knocked down, including the veteran. According to the veteran, he was taken for x-rays and he may have had a hairline fracture. The veteran stated that the injury improved somewhat after service, but it began to worsen approximately fifteen years ago. During the hearing, the veteran identified a Dr. Casper in Oklahoma City, Oklahoma, as a private treatment provider. The veteran stated that Dr. Casper diagnosed the veteran with a pinched nerve in the low back. According to the veteran, Dr. Casper stated that the right hip and right leg pain were secondary to the pinched nerve and that the disability could be related to the in-service injury. Because the records from Dr. Casper have not been requested and associated with the claims file, a remand is necessary in order to attempt to obtain the potentially relevant medical evidence. In addition to the record request, the veteran should be scheduled for a VA examination in order to address the nature of the veteran's disability affecting the right hip and right leg. Although the service medical records are negative for any complaints or symptoms of right hip or right leg pain, including the training injury, the veteran is competent to report factual matters of which he had first hand knowledge, such as that injury. See Washington v. Nicholson, 19 Vet. App. 362 (2005). Thus, along with the examination, a medical opinion should be obtained that addresses whether the veteran has a disability manifested by right hip and right leg pain that is related to the stated in-service injury. An opinion is also necessary to address the possibility of post-service onset if a disability is found. Records from the Southwest Medical Center of Oklahoma document that the veteran was involved in a motor vehicle accident in September 1991. Treatment records and x-ray reports indicate injury to the spine, particularly the cervical spine, at that time. Additionally, it was noted that the veteran's post- service occupation entailed heavy lifting. Finally, a record indicates that the veteran fell in approximately November 2002 and injured his right side. These aspects should be addressed in the opinion issued by the examiner. During the hearing, the veteran stated that he believes that some of his service medical records may be missing. However, because records from Camp Pendleton have already been obtained, there is no suggestion that the records are incomplete. No further requests for service medical records are necessary. The Board notes that several of the veteran's submissions were made by a service organization. Yet, the claims file indicates that the veteran is unrepresented. The veteran should be asked to clarify whether he wishes to have a representative for the claims process and, if so, to sign the applicable forms. Accordingly, this case is REMANDED for the following actions: 1. Give the veteran an opportunity to appoint a representative and to supplement the record on appeal. 2. Request treatment records from Dr. Casper in Oklahoma City. Obtain a release from the veteran as necessary. 3. Schedule the veteran for a VA examination. The entire claims file, to include a complete copy of this remand, should be made available to, and reviewed by, the examiners designated to examine the veteran. All appropriate tests and studies should be performed and all clinical findings should be reported in detail. The examiner should determine the current diagnosis, if any, of a disability pertaining to the veteran's complaints of right hip and right leg pain. Based on a thorough review of the evidence of record, the examiner should provide an opinion as to the medical probabilities that the veteran has such a current disability that is related to his period of military service, particularly his stated in-service training injury. The examiner should also indicate whether any such disability is more likely than not of post-service onset (September 1991 motor vehicle accident, type of employment, and fall in approximately November 2002). All opinions should be set forth in detail and explained in the context of the record. After the requested examination has been completed, the report should be reviewed to ensure that it is in complete compliance with the directives of this remand. If the report is deficient in any manner, it should be returned to the examiner. (The veteran should be advised that failure to appear for an examination as requested, and without good cause, could adversely affect his claim. See 38 C.F.R. § 3.655 (2007).) 4. After undertaking any other development deemed appropriate, re- adjudicate the issue on appeal. If the benefit sought is not granted, furnish the veteran and any duly appointed representative with a supplemental statement of the case (SSOC) and afford them an opportunity to respond before the record is returned to the Board for further review. By this remand, the Board intimates no opinion as to any final outcome warranted. No action is required of the veteran until he is notified by VA. The veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This case must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2007). ________________________________ MARK F. HALSEY Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2007).