Citation Nr: 18158873 Decision Date: 12/19/18 Archive Date: 12/18/18 DOCKET NO. 16-42 699 DATE: December 19, 2018 ORDER Entitlement to service connection for left hip bursitis is granted. REMANDED Entitlement to service connection for a left knee condition is remanded. Entitlement to service connection for an acquired psychiatric disorder, including posttraumatic stress disorder (PTSD) and an adjustment disorder with anxiety, is remanded. FINDING OF FACTS The Veteran’s left hip bursitis had its onset during service. CONCLUSION OF LAW The criteria for service connection for left hip bursitis are satisfied. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran’s served on active duty from October 2010 to October 2014. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2015 rating decision of the Department of Veteran Affairs (VA) Regional Office (RO) in San Diego, California. 1. Entitlement to service connection for left hip bursitis is granted. Service connection will generally be awarded when a veteran has a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish service connection on a direct basis, the evidence must show (1) a current disability; (2) incurrence or aggravation of a disease or injury in service; and (3) a link or nexus between the in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 252 (1999). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. When the evidence supports the claim, or is in relative equipoise, the claim will be granted. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). If the preponderance of the evidence weighs against the claim, it must be denied. Id.; Alemany v. Brown, 9 Vet. App. 518, 519 (1996). While in service the Veteran’s left hip began clicking. See March 2013 Medical Record (reflecting hip pain and clicking started in June 2012 with a gradual onset with running). He was diagnosed as having left hip bursitis in March 2013. His post-service VA treatment records show that he was again diagnosed as having left hip bursitis on October 24, 2014, shortly after his separation from service. At that time, he reported experiencing pain and clicking in his left hip intermittently for the past year. The examiner noted clicking in the left hip on rotation. The Board acknowledges that a VA examiner in May 2015 found that there was insufficient evidence to diagnose a hip condition; however, given the diagnosis of left hip bursitis during service in March 2013 and again after service in October 2014, in addition to the Veteran’s competent and credible statements concerning a continuity of left hip symptomatology since service, the Board resolves reasonable doubt in favor of the claim and finds that the Veteran’s left hip bursitis had its onset during service. As such, service connection is granted. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 55. REASONS FOR REMAND 1. Entitlement to service connection for a left knee condition is remanded. While in service, the Veteran injured his left knee after falling and landing on his knee in 2013. He reported knee trouble at the time of his September 2014 separation examination. See September 2014 Report of Medical History; May 2015 VA C&P Examination Report. He was diagnosed as having patellofemoral syndrome and iliotibial band friction syndrome. See STRs, dated August 13, 2014 and September 24, 2014. The Veteran was afforded a VA examination in May 2015. The examiner noted that there was insufficient evidence to diagnose a knee condition. However, a March 2016 VA treatment record showed that the Veteran complained of left knee pain, with mild tenderness noted at the lateral aspect of the knee on examination. Therefore, on remand the Veteran should be scheduled for an additional VA examination to clarify whether he has a current left knee disorder or any functional impairment of his left knee related to his military service. See Saunders v. Wilkie, 886 F.3d 1356, 1367-68 (2018). 2. Entitlement to service connection for an acquired psychiatric disorder, including PTSD and an adjustment disorder with anxiety, is remanded. The Veteran’s post deployment records indicate mild symptoms of PTSD. See September 2014 Health Record; September 2014 STR. However, after service a VA medical record noted the Veteran showed subclinical symptoms of PTSD but did not meet the fill criteria. Instead, the Veteran was diagnosed as having an adjustment disorder with anxiety (associated with combat-related stress). See November 2014 Psychological Intake. The Veteran underwent a VA examination in May 2015. The examiner found the Veteran to endorse symptoms of anxiety and past symptoms of jumpiness and irritability. The examiner noted that the Veteran did not meet the clinical criteria for PTSD or any other psychiatric disorder under DSM-V. The examiner noted that while the Veteran had some PTSD symptoms in the past, they have resolved and did not reach a severity necessary to justify a diagnosis. See June 2015 VA C&P Examination Report. The Veteran’s therapist at the San Marcos Veterans’ Center stated that he had been attending services since January 2016. The therapist noted that the Veteran has symptoms of recurrent memories of a traumatic event, distressing dreams, avoidance of memories, irritable behaviors, angry outbursts, hypervigilance, and sleep disturbance. See February 2016 Third Party Correspondence. Accordingly, as there appear to be outstanding medical treatment reports from the San Marcos Veteran Center efforts, should be undertaken to obtain them. In addition, on remand a new examination should be conducted to determine whether the Veteran meets the criteria for PTSD or any other psychiatric disorder under DSM-V. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c)(2). The matters are REMANDED for the following action: 1. Make arrangements to obtain the Veteran’s complete treatment records from the San Marcos Veterans’ Center dating from January 2016 forward. 2. Make arrangement to obtain any outstanding VA treatment records dated from July 2016 forward. 3. Schedule the Veteran for a for an appropriate VA of his left knee. The entire claims file and a copy of this REMAND must be made available to the examiner in conjunction with the examination. The examiner must note in the examination report that the evidence in the claims file has been reviewed. The examination should include any diagnostic testing or evaluation deemed necessary by the examiner. After reviewing the file, the examiner must render an opinion as to the following: (a) Identify all left knee disorders found to be present since October 2014. (b) If the examiner concludes that there is no underlying pathology to diagnose a left knee disorder, he/she should identify all functional impairment associated with the Veteran’s left knee symptoms (i.e., pain, decreased range of motion during flare-ups and over-use, etc.). See Saunders v. Wilkie, 886 F.3d 1356, 1367-68 (2018). If there is no functional impairment of the left knee, the examiner should so state. (c) For any left knee diagnosis and/or functional impairment of the left knee, provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that it had its clinical onset during active service or is related to any incident of service, to include carrying heavy gear and/or the incident when the Veteran fell and landed on his left knee in 2013 with subsequent diagnoses of patellofemoral syndrome and iliotibial band friction syndrome. See STRs, dated August 13, 2014 and September 24, 2014; and September 2014 separation examination; see Statement of Representative in Appealed Case dated September 15, 2016 referencing a “study by a Navy research advisory committee, Marines typically have loads from 97 to 135 pounds and the increasing number of musculoskeletal injuries is direct result of carrying excessive load for long period. http:// www.seattletimes.com/nation-world/weight-of-war-gear-that-protects-troops-also-injures-them/” The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached. 4. Schedule the Veteran for a VA psychiatric examination. The entire claims file and a copy of this REMAND must be made available to the examiner in conjunction with the examination. The examiner must note in the examination report that the evidence in the claims file has been reviewed. The examination should include any diagnostic testing or evaluation deemed necessary by the examiner. After reviewing the file, the examiner must render an opinion as to the following: (a) Identify all psychiatric disorders found to be present since October 2014, i.e., PTSD, adjustment disorder with anxiety, etc. (c) For any diagnosed psychiatric disorder, provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that it had its clinical onset during active service or is related to any incident of service, to include the Veteran’s reported in-service stressors. The examiner should consider the September 2014 service treatment record showing that the Veteran was referred to mental health for symptoms of mild PTSD, as well as the post-service VA treatment record dated in November 2014 showing that he was diagnosed as having an adjustment disorder with anxiety associated with combat-related stress. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached. P.M. DILORENZO Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD L. Sinckler, Associate Counsel