Citation Nr: 18160267 Decision Date: 12/26/18 Archive Date: 12/26/18 DOCKET NO. 16-58 677A DATE: December 26, 2018 ORDER Service connection for a right hip arthritis and total hip replacement, as secondary to service-connected residuals of a shell fragment wound (SFW) of the left thigh and knee, is granted. REMANDED Service connection for a low back disorder is remanded.   FINDING OF FACT The Veteran’s right hip disorder is related to his service-connected residuals of a SFW of the left thigh and knee. CONCLUSION OF LAW The criteria for establishing service connection for a right hip arthritis and total hip replacement, as secondary to residuals of a SFW of the left thigh and knee, have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from April 1968 to April 1970. The case is on appeal from a March 2015 rating decision. Service connection for a right hip disorder. Legal Criteria Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303. “To establish a right to compensation for a present disability, a veteran must show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service”-the so-called “nexus” requirement.” Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. See 38 C.F.R. § 3.310. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Analysis The Veteran contends his current right hip disorder is related to his service-connected disabilities, including SFWs he received during his combat service in Vietnam. The Veteran’s service treatment records (STRs) show he was severely injured during service, including sustaining SFWs to various areas of his body. In December 2014, the Veteran indicated that, after being injured in service, his left thigh and left knee disability caused him problems over the following years. He stated the injuries progressively worsened and altered his gait. He asserted this led to excessive wear and tear on his right hip and ultimately, severe arthritis and a hip replacement. The Veteran was afforded a March 2015 VA examination in which the examiner diagnosed him with right hip osteoarthritis that progressed to total right hip replacement, which occurred in January 2015. The examiner indicated she could not provide a nexus opinion without resorting to speculation as to whether his right hip disorder is related to a service-connected condition. A February 2016 medical opinion was received from Dr. R.H. who is an orthopedic surgeon at a VA Medical Center. He noted the Veteran reports he sustained a left thigh and knee injury in service as a result of shrapnel wounds and that the injuries caused him to favor his left side, leading to increased stress on his right side. Dr. R.H. indicated the Veteran’s severe arthritis which developed in the right hip could certainly be caused from having favored his left side following the injuries he sustained during his service in Vietnam. Dr. R.H. stated, “The severe arthritis and resulting total right hip replacement is more likely than not secondary to the thigh wound as well as the service connected left knee wound.” After a review of the evidence, the Board determines it has reached at least a level of equipoise as to the secondary nexus element of the claim. The Board finds the February 2016 medical opinion from Dr. R.H. to be persuasive and of the greatest probative value. The physician’s opinion was based on an accurate history and contained a well-reasoned explanation related to the etiology of the Veteran’s right hip disorder. As such, this opinion is entitled to significant probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008). While the March 2015 VA examiner could not provide a nexus opinion without resorting to speculation, the February 2016 physician adequately reasoned the Veteran’s right hip disability is related to his service-connected shrapnel wound of the left thigh and knee. Therefore, the Board finds the February 2016 opinion to be more probative than the March 2015 VA examination report. The Board determines the evidence overall reaches at least a level of equipoise as to the nexus element, under the secondary service connection theory of entitlement. Thus, when resolving any reasonable doubt in the Veteran’s favor, the Board finds that his right hip disorder was caused by his service-connected residuals of a SFW of his left thigh and knee. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Accordingly, service connection is warranted for the right hip disability on a secondary basis, which is best characterized as right hip arthritis and total hip replacement. REASONS FOR REMAND Service connection for a low back disorder. The Veteran also contends that he has a low back disorder is related to his service-connected shrapnel wounds of the left thigh and knee. Alternatively, he asserts his low back disorder is directly related to service, including his in-service SFW. Post-service medical evidence includes an April 1985 VA treatment record that indicated the Veteran had a lumbosacral strain and a January 1989 record that noted chronic low back pain. Further, an April 1989 VA record indicated chronic low back pain and a June 1990 record reported a “constant ache” in the Veteran’s low back area. In December 2014, the Veteran stated he has arthritis in his lower back which was caused by the change in the way he walks due to his left thigh and knee injuries. Additionally, he indicated the explosion in service which threw him into the air caused him to land on dry mud, which contributed to his low back disorder. The Veteran was afforded a March 2015 VA examination in which the examiner indicated no low back diagnosis could be provided. However, she noted the Veteran reported a gradual onset of back pain and constant pain of a severity level of 3-4/10. She stated there is no evidence of a back diagnosis or condition outside of pain and that his mild degenerative changes of the lumbar spine are within age appropriate limits. The Board notes the VA treatment records show complaints of back pain from the Veteran. The Board finds a new VA examination is warranted. The examiner detailed the Veteran’s complaints of back pain, as well as mild degenerative changes in his lumbar spine. However, she indicated the Veteran does not have a back diagnosis. The Board finds the Veteran has consistently reported low back pain throughout the record and that such is related to his service-connected SFW of the left thigh and knee. The Veteran’s competent lay statements, as well as the severity of his SFW, tend to suggest a history of recurrent symptoms. Furthermore, pain alone may constitute a disability, even without an identifiable pathology. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). Thus, a new VA examination and a medical opinion should be obtained. Prior to the examination, any outstanding records of pertinent VA medical treatment must be obtained and added to the record. The matter is REMANDED for the following action: 1. Obtain complete VA treatment records since January 2017. 2. Thereafter, schedule the Veteran for a VA examination by an appropriate medical professional to determine the nature and etiology of any low back disability. The entire claims file should be reviewed. Any necessary tests should be performed. The examiner should first identify whether the Veteran has a diagnosis of a low back disability. If not, the examiner should The examiner should then provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that any identified low back disability was caused or aggravated by his service-connected residuals of SFW of the left thigh and knee. Aggravation is an increase in severity beyond the natural progress of the condition. If not, the examiner should opine as to whether it is at least as likely as not (a 50 percent or greater probability) that any back disability had its onset during, or is otherwise related to, service, to include his combat service and in-service injury involving SFW. (Continued on the next page)   The Veteran’s lay statements should be addressed. A complete rationale or explanation should be provided for all opinions. RYAN T. KESSEL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Isaacs, Associate Counsel