Citation Nr: 1702301 Decision Date: 01/27/17 Archive Date: 02/09/17 DOCKET NO. 12-08 396 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for a head injury or its residuals, status post fall. 2. Entitlement to service connection for left hip labral tear. REPRESENTATION Appellant represented by: Virginia Department of Veterans Services ATTORNEY FOR THE BOARD K. M. Schaefer, Counsel INTRODUCTION The appellant served on active duty training from September 2004 to March 2005, from March 2009 to July 2009, and from February 2015 to April 2015. She has not served on active duty. This appeal comes before the Board of Veterans' Appeals (Board) from an August 2011 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. The record before the Board consists solely of electronic records within Virtual VA and the Veterans Benefits Management System (VBMS). REMAND The appellant contends that she has a head injury and left hip disability that are a result of a fall during a training exercise in March 2006. With respect to the head injury, the record shows that she was scheduled for a VA examination in April 2012 to assess the existence and etiology of the disability. However, due to her work and school obligations, the appellant chose to cancel the examination. Given that it is now almost five years later and the appellant's desire and ability to attend an examination has potentially changed, the Board determines that the head injury claim should be remanded so that another VA examination may be scheduled. A VA opinion as to the etiology of the appellant's left hip disability was received in November 2011. The examiner opined that there is no evidence that the appellant suffered a fall of a sufficient nature in service to traumatize her hip and result in what has become a chronic unremitting medical issue. However, while the immediate clinical examination and image yielded no diagnosis of a left hip disability, just 22 days later, the appellant was diagnosed with left trochanteric bursitis, and the physician noted that the appellant's disability may be related to her fall. In March 2008, the appellant was being treated for hip joint irritability and her fall was noted as the incipient injury. The appellant continued to need treatment for her left hip through at least 2010, when she filed her claim. At that time, she was being treated for overuse of the iliotibial band with a labral tear noted in the appellant's primary medical history. In light of these facts, the Board determines that the examiner's statement that there is "no evidence" that the fall in service could have resulted in the appellant's current disability to be conclusory and lacking in a complete rationale. Additionally, the most recent treatment evidence is dated in 2010. Therefore, the appellant should be asked to identify any outstanding, relevant treatment notes and to submit or authorize release of the records to VA. Accordingly, this case is REMANDED to the RO or the Appeals Management Office (AMO), in Washington, D.C., for the following actions: 1. The RO or the AMO should undertake appropriate development to obtain any outstanding records pertinent to the appellant's claim. The appellant should be specifically requested to identify any relevant treatment received since 2010 and to submit or authorize release of those records to VA. All requests and responses, positive and negative, should be associated with the claims file. 2. Then, the appellant should be afforded an examination by a physician with sufficient expertise to determine the existence and etiology of a head injury or its residuals, present during the period of the claim. All pertinent evidence of record must be made available to and reviewed by the examiner, and any indicated tests and studies should be performed. Based on the review of the record and examination of the appellant, the examiner should state a medical opinion with respect to any head injury or residuals present during the period of the claim as to whether it is at least as likely as not (i.e., whether there is a 50 percent or better probability) that the disorder(s) originated as a result of the March 2006 fall or are otherwise etiologically related to a period of ACDUTRA or INACDUTRA. For purposes of the opinions, the examiner should assume that the appellant is a reliable historian. The examiner must not ignore the appellant's competent reports of the claimed in-service injury or of symptoms experienced during active service and since. The rationale for each opinion expressed must also be provided. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 3. Then, the appellant should be afforded an examination by a physician with sufficient expertise to determine the nature and etiology of all left hip disabilities present during the period of the claim. All pertinent evidence of record must be made available to and reviewed by the examiner, and any indicated tests and studies should be performed. Based on the review of the record and examination of the appellant, the examiner should state a medical opinion with respect to each left hip disability present during the period of the claim as to whether it is at least as likely as not (i.e., whether there is a 50 percent or better probability) that the disorder originated as a result of the March 2006 fall or is otherwise etiologically related to a period of ACDUTRA or INACDUTRA. For purposes of the opinions, the examiner should assume that the appellant is a reliable historian. The examiner must not ignore the appellant's competent reports of the claimed in-service injury or of symptoms experienced during active service and since. The rationale for each opinion expressed must also be provided. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 4. The RO or the AMO should also undertake any other development it determines to be warranted. 5. Then, the RO or the AMO should readjudicate the issue remaining on appeal. If the benefit sought on appeal is not granted to the appellant's satisfaction, a supplemental statement of the case should be issued to the appellant and her representative, and they should be afforded the requisite opportunity to respond. Thereafter, the case should be returned to the Board for further appellate action. By this remand, the Board intimates no opinion as to any final outcome warranted. The appellant need take no action until he is otherwise notified, but he may furnish additional evidence and/or argument during the appropriate time frame. See Kutscherousky v. West, 12 Vet. App. 369 (1999). This REMAND 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 2014). ______________________________________________ T. REYNOLDS Veterans Law Judge, Board of Veterans' Appeal