Citation Nr: 1336833 Decision Date: 11/13/13 Archive Date: 11/26/13 DOCKET NO. 12-04 369 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUE Entitlement to service connection for a right hip disorder. ATTORNEY FOR THE BOARD Sara Schinnerer, Counsel INTRODUCTION The Veteran had active service from July 1968 to July 1972. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. The record before the Board consists of the Veteran's paper claims files and an electronic file known as Virtual VA. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action is required. REMAND The Veteran contends that his current right hip disorder had its onset during active service. Specifically, he stated that he injured his right hip in January 1969 at Keesler Air Force Base, as a result of pushing a vehicle. He further stated that he received treatment at the base, and was excused from marching training class for one week. He indicated that during the week he was injured, he was allowed to drive his car to the training facility. He also asserted that he has experienced periodic right hip pain since the in-service injury. Service treatment records include a January 1969 record that notes the Veteran's complaint of right side back pain due to pushing a car the day before. Examination revealed tenderness over the right lateral hip. The May 1972 separation physical examination report notes the Veteran's complaint of swollen or painful joints. Clinical examination of the lower extremities was normal; there was no noted diagnosis pertaining to the right hip. Post-service private treatment records dated in April 2010 through February 2012 demonstrate the Veteran's reports of intermittent right hip pain that had worsened over the years. In an April 2010 record, A.F., M.D. diagnosed right sciatica. Records dated in 2012 note the Veteran's complaints of ongoing hip pain for the past 40 years, as well as diagnoses of recurrent right sciatica pain. In a June 2012 record, S.M., D.O. indicated that he did not believe that the Veteran's right hip pain was a result of his thoracolumbar spine, and explained that he felt it was the result of a muscle or tendon fiber tear. In September 2010, the Veteran underwent a fee-based examination. At the time, the Veteran reported that his right hip problem had existed since 1969. Upon examination, the examiner diagnosed a chronic right hip strain. The examiner opined that the Veteran's current right hip condition was not related to his one-time treatment in January 1969 for tenderness over the right lateral hip because his right hip did not hurt again until January 2010. The Board finds the September 2010 VA opinion to be inadequate for adjudication purposes. The examiner based his opinion in pertinent part, upon an inaccurate assessment of the record. Specifically, the examiner found that the Veteran's current right hip strain was not related his in-service treatment, because the right hip did not hurt again until January 2010. In this regard, the record demonstrates the Veteran's repeated reports of intermittent right hip pain since service. Moreover, as noted above, there is evidence showing the presence of right sciatica during the period of the claim. Therefore, a medical opinion addressing the etiology of the currently diagnosed right hip strain and right sciatica with consideration of all of the pertinent evidence of record is necessary to make a determination in this case. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Following the February 2012 supplemental statement of the case, additional records were added to the claims file that the RO has not considered, private treatment records dated from February 2012 through September 2012. This evidence is relevant to the Veteran's instant claim for service connection, and a waiver of RO consideration of such evidence has not been received. Therefore, the additional evidence must be considered by the RO. 38 C.F.R. §§ 19.37, 20.1304 (2013). Accordingly, the case is REMANDED for the following actions: 1. The claims files and all records on Virtual VA must be made available to the September 2010 fee-based examiner, in order for the examiner to offer an addendum opinion addressing the etiology of the Veteran's current right hip disorders, to include right hip strain and right sciatica. The examiner must specify in the addendum report that the claims file and Virtual VA records have been reviewed. If the fee-based examiner that conducted the September 2010 examination is unavailable, an appropriate VA examiner must be directed to provide the supplemental opinions to the September 2010 fee-based examination. If the VA examiner determines another examination is necessary to provide the finding, an examination must be scheduled. Based on the September 2010 examination findings and review of the record, the examiner must opine as to whether any currently diagnosed right hip disorder, to include right hip strain and right sciatica is at least as likely as not incurred in, or otherwise related to the Veteran's military service. In doing so, the examiner must comment on the Veteran's service treatment records of record, which include a January 1969 record that notes the examiner's finding of tenderness over the right lateral hip associated with the Veteran's report of pushing a car the day before. The examiner must also comment on the contemporaneous private treatment records of record, which indicate diagnoses of right sciatica, as well as note the Veteran's report of intermittent right hip pain for the past 40 years. The addendum report must include a complete rationale for all opinions expressed. 2. The addendum report must be reviewed by the RO/AMC to ensure that it is in complete compliance with the directives of this remand. If the report is deficient in any manner, the RO/AMC must implement corrective procedures. 3. If another VA examination is deemed necessary, the Veteran must be advised of the importance of reporting to such examination and of the possible adverse consequences of failing, without good cause, to so report. See 38 C.F.R. § 3.655 (2013). A copy of any notification letter sent to the Veteran regarding any scheduled examinations must be included in the claims folder and must reflect that it was sent to his last known address of record. If he fails to report to any scheduled examination, the claims folder must indicate whether the notification letter was returned as undeliverable. 4. Thereafter, readjudicate the Veteran's claim, with application of all appropriate laws and regulations, taking into consideration any newly acquired evidence submitted without a waiver of RO jurisdiction. If the decision with respect to the claim remains adverse to the Veteran, he must be furnished a supplemental statement of the case and afforded a reasonable period of time within which to respond thereto. 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 claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals 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. 2012). _________________________________________________ L. M. BARNARD Acting Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals 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) (2013).