Citation Nr: 18153033 Decision Date: 11/27/18 Archive Date: 11/26/18 DOCKET NO. 15-03 713A DATE: November 27, 2018 REMANDED Entitlement to service connection for a low back disability is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for a right ankle disability is remanded. Entitlement to service connection for bilateral hearing loss is remanded. REASONS FOR REMAND 1. Entitlement to service connection for a low back disability is remanded. The Board cannot make a fully-informed decision on the issue of whether the claimed low back disability is related to service or any incident of service, because the only examination report regarding the etiology of the Veteran's low back disability is incomplete. In a November 2013 VA medical examination report, a VA examiner found that the Veteran did not have a current low back disability except for a functional limitation of extension due to pain. The Board notes that pain resulting in functional limitation can be considered a disability under VA regulations. Moreover, the examiner did not note reviewing any records, except for the service medical records. Even in reviewing those records, the examiner did not note a July 1980 service medical record which shows that the Veteran sought treatment after injuring his back during a fall from a truck. The examiner also stated that there was no lay evidence of any recurrent back disabilty symptomatology, despite that day’s interview during which the Veteran reported experiencing recurrent back disability symptoms since service. Because of those contradictory findings and incomplete review of the medical history, a remand is necessary to schedule an additional VA medical examination to determine the etiology of the claimed low back disability. 2. Entitlement to service connection for a left knee disability is remanded. 3. Entitlement to service connection for a right knee disability is remanded. The Veteran underwent treatment for lower leg and knee disorders during service. In a November 2013 VA medical examination report, a VA examiner found that the Veteran did not have any knee disability. Since that examination, in April 2015, a private examiner diagnosed degenerative joint disease in both knees. As the Veteran has been diagnosed with right and left knee disabilities since the most recent VA medical examination, a remand is necessary to schedule an additional VA medical examination to determine the etiologies of now diagnosed right and left knee disabilities. 4. Entitlement to service connection for a right ankle disability is remanded. The Veteran underwent treatment for a right ankle disability during service. In a November 2013 VA medical examination report, a VA examiner found that the Veteran did not have any right ankle disability. However, in a February 2014 private treatment record, the Veteran reported experiencing increasing right ankle pain. A remand is necessary to schedule an additional VA medical examination to determine the etiology of any current right ankle disability. 5. Entitlement to service connection for bilateral hearing loss is remanded. In a November 2013 VA audiology examination report, a VA examiner, in finding that the Veteran's claimed tinnitus disability was related to service, conceded that the Veteran experienced exposure to high-intensity noise during service. However, the VA examiner also opined that the Veteran's claimed hearing loss disability was less likely than not related to service, because the Veteran’s hearing thresholds were normal at the time of separation from service. In making that finding, the examiner ignored the Veteran's lay reports of hearing loss before and after service. Additionally, in a January 2015 private treatment record, a private examiner stated that the Veteran's current hearing loss was related to service, because, in part, the Veteran stated that a service examiner found that the Veteran had a hearing abnormality at the time discharge. The Board notes that, while the Veteran has made lay statements indicating in-service hearing loss, the service medical records contains no notations indicating diagnosis or treatment for any in-service hearing abnormality. A remand is necessary to schedule an additional VA audiology examination to determine the etiology of any current bilateral hearing loss disability. A February 2014 indicates that there may be outstanding and relevant Social Security Administration (SSA) records. A remand is required to allow VA to request these records. The matters are REMANDED for the following action: 1. Obtain the Veteran’s federal records from SSA. Document all requests for information and all responses in the claims file. 2. Schedule the Veteran for an examination by a VA orthopedist to determine the nature and etiology of any low back, bilateral knee, or right ankle disability diagnosed during the pendency of the appeal, dating to April 2013. In writing the report, the examiner should refer to the service medical records, indicating in-service treatment for low back, leg, and knee injuries; the post-service treatment records; and the Veteran's lay statements, indicating orthopedic symptomatology both during and after service. The examiner must opine as to the following: a. Is it at least as likely as not (50 percent probability or greater) that any low back disability diagnosed during the pendency of the appeal, dating to April 2013, to include pain resulting in functional impairment, is related to an in-service injury, event, or disease, including the Veteran's reported in-service back injury? b. Is it at least as likely as not (50 percent probability or greater) that any right knee disability diagnosed during the pendency of the appeal, dating to April 2013, to include pain resulting in functional impairment, is related to an in-service injury, event, or disease, to include noted in-service treatment for lower leg disability symptomatology? c. Is it at least as likely as not (50 percent probability or greater) that any left knee disability diagnosed during the pendency of the appeal, dating to April 2013, to include pain resulting in functional impairment, is related to an in-service injury, event, or disease, to include noted in-service treatment for left knee disability symptomatology? d. Is it at least as likely as not (50 percent probability or greater) that any right ankle disability diagnosed during the pendency of the appeal, dating to April 2013, to include pain resulting in functional impairment, is related to an in-service injury, event, or disease, including the Veteran's reported in-service back injury, to include noted in-service treatment for right ankle disability symptomatology? 3. Schedule the Veteran for a VA audiology examination by an appropriate clinician to determine the nature and etiology of any bilateral hearing loss disability. In writing the report, the examiner should note and refer to the service medical records, the post-service treatment records, and the Veteran's lay reports of his hearing loss symptomatology. The examiner must opine whether the claimed bilateral hearing loss is at least as likely as not (50 percent probability or greater) related to any in-service injury, event, or disease, including conceded noise exposure during service. Harvey P. Roberts Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T.M. Gillett, Counsel