Citation Nr: 18123735 Decision Date: 08/03/18 Archive Date: 08/02/18 DOCKET NO. 15-16 433 DATE: August 3, 2018 ORDER Service connection for a right hip disorder as secondary to the service-connected left ankle and left foot disabilities is denied. REMANDED Service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is remanded. FINDING OF FACT The right hip disorder is not causally related to or worsened by the service-connected left ankle and left foot disabilities. CONCLUSION OF LAW The criteria for service connection for a right hip disorder secondary to the service-connected left ankle and left foot disorders have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran, who is the Appellant, served on active duty from November 1990 to November 1994. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a July 2014 rating decision from the Regional Office (RO), which denied service connection for a right hip disorder and an acquired psychiatric disorder. In June 2018, the Veteran testified at a Board videoconference hearing from the RO in Roanoke, Virginia, before the undersigned Veterans Law Judge in Washington, DC. The hearing transcript has been associated with the record. The duties to notify and assist regarding the issue of service connection for an acquired psychiatric disorder are reserved for the REMAND section of this decision. With regard to the claim for service connection for a right hip disorder, the Board finds that the duties to notify and assist the appellant in this case have been fulfilled. Neither the appellant nor the evidence has raised any specific contentions regarding the duties to notify or assist. Service Connection for a Right Hip Disorder Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may be established on a secondary basis for disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a disorder which is aggravated by a service-connected disability; compensation may be provided for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(c). Establishing service connection on a secondary basis essentially requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service connected disability. 38 C.F.R. § 3.310(c). The Veteran generally contends that service connection for a right hip disorder is warranted as secondary to the service-connected left ankle and left foot disabilities. Specifically, the Veteran contends that she has compensated pain from the service-connected left ankle and foot disabilities by shifting weight to the right side of her body, causing right hip pain and stiffness that has progressively worsened over the years. See May 2015 VA Form 9; December 2012 correspondence, and June 2011 Claim. At the outset, the Board finds that service treatment records do not reflect evidence of symptoms, clinical signs, treatment, or diagnosis of a right hip disorder during service to even suggest a direct service connection theory. See generally, service treatment records. Further, the Veteran has only advanced the theory of service connection for a right hip disorder secondary to the service-connected left ankle and left foot disabilities in this case. See June 2011 Claim, December 2012 correspondence, and May 2015 VA Form 9. Therefore, the question in this case is whether the right hip disorder was caused or aggravated by the service-connected left foot and left ankle disabilities. 38 C.F.R. § 3.310(a). The Board finds that the Veteran is currently diagnosed with a right hip disorder, including mild osteoarthritis, right trochanteric bursitis, and iliotibial band (ITB) syndrome of the right hip. See June 2014 VA examination report, see also July 2016 VA treatment record. After reviewing all the evidence of record, both lay and medical, the Board finds that the weight of the evidence is against finding that the right hip disorder was caused by or worsened by the service-connected left foot and ankle disabilities. A June 2010 MRI of the left foot showed minimal tenosynovitis and minimal retrocalcaneal bursitis but was otherwise unremarkable. See June 2010 VA treatment record. VA treatment records dated January and February 2011 reflect that the Veteran reported right hip pain that was gradually increasing over the past three months, particularly the past three weeks, and that she believed the pain in her right hip was due to off-loading the weight from her left ankle and foot to the right leg due to the chronic left ankle problem. Examination revealed that the Veteran was able to heel and toe walk with some right hip pain and she had mildly limited right hip range of motion, but otherwise full strength. Diagnosis was right trochanteric bursitis and ITB syndrome for which physical therapy was recommended. See January 2011 and February 2011 VA treatment records. An August 2012 magnetic resonance imaging (MRI) of the right hip showed mild osteoarthritis. See August 2012 VA treatment record. The Veteran sought follow up treatment for the hip pain between 2015 and 2016. At the time, the Veteran provided a history of a rheumatoid arthritis diagnosis three years prior, as the podiatrist informed her that she had a positive rheumatoid factor. She reported that her initial symptoms were first metatarsophalangeal (MTP) pain and hip pain. The Veteran also denied any trauma to the hip and reported a history of left foot and ankle pain that started after an injury, which she believed made her right trochanteric bursa pain worse. While the Veteran exhibited pain with range of motion in both hips, right greater than left, she had full range of motion with no swelling or deformity in the left ankle and foot, only mild tenderness in the left foot and ankle and no limp on ambulation. Additionally, laboratory testing revealed a positive rheumatoid factor and positive antinuclear antibody (ANA) despite no clinical signs of inflammatory arthritis and lupus. Diagnosis was chronic hip pain secondary to trochanteric bursitis and ITB syndrome. See March 2015, May 2015, July 2015, July 2016. The Veteran underwent a VA examination in June 2014. Upon interview and examination, the VA examiner diagnosed mild osteoarthritis of the right hip. The June 2014 VA examiner opined that the right hip disorder was less than likely due to the service-connected left ankle disability. The VA examiner reasoned that there was no evidence based on medical literature that suggests lateral instability of the left ankle caused osteoarthritis. The June VA 2014 VA examiner further explained that the Veteran does not have abnormal gait, imaging of the left ankle was normal, and a left ankle disorder anatomically cannot cause a hip condition. See June 2014 VA examination report. Following a review of the claims file, including VBMS and Virtual VA, an addendum VA medical opinion was provided in March 2015. The March 2015 VA examiner opined that it was less than likely that the right hip disorder was caused by or aggravated beyond its natural progression by the service connected left ankle instability or left heel calcaneal spur. The March 2015 VA examiner explained that, while the contention that one side of the body having pain causes a person to favor or “on load” on the other causing arthritis on the contralateral side is often cited, this theory is biomechanically incorrect and has been disproven in the orthopedic and occupational medicine literature. The March 2015 VA examiner explained that arthritis formation would require increase speed and increase sheer forces across the joint, which is only seen in the paralytic or waddling gait abnormality; the veteran has intermittent pain in the left ankle but wears a brace for stability, offsetting any effect. Citing the American Academy of Orthopedic Surgeons (March 2014) to support the rationale, the VA examiner further reasoned that hip bursitis is caused by repetitive stress injury from sports, running, stair climbing, excess standing; direct injury to the hip; spine disease; significant leg length abnormality; rheumatoid arthritis; and prior hip surgery and hip tendon bone spurs. Additionally, the March 2015 VA examiner endorsed the same disclaimer concerning contralateral “favoring” as discussed above as relevant for arthritis, and explained that there is no plausible mechanism for a heel spur to cause any condition of the right hip. When considered in light of the entire record, the Board finds the June 2014 and March 2015 VA medical opinions to be highly probative, as they are supported by thorough rationale that relies on medical authorities regarding the causes of arthritis and bursitis in the hip and considers the evidence of record to support their rationale, including the unremarkable imaging of the left ankle, mitigation of left ankle and foot disabilities with bracing, and lack of antalgic gait on examinations. In a February 2011 treatment note and a December 2012 letter, the Veteran’s treating physician and occupational therapist both opined that the Veteran’s right hip problem is secondary to the service-connected left ankle disability. They reasoned that the left ankle instability caused the Veteran to off-load or add more stress to her right side to help compensate the pain from her left foot and ankle disorder. See February 2011 VA treatment record; December 2012 Third Party Correspondence. The Board gives these opinions little weight, as they do not consider Veteran’s later lay statements that right hip pain first manifested as a symptom of rheumatoid arthritis; the finding of positive rheumatoid factor; other treatment records relating the right hip disorder is secondary to trochanteric bursitis and ITB syndrome; and the lack of evidence of antalgic gait to indicate off-loading weight from the left lower extremity to the right lower extremity despite a history of left ankle and foot pain. For these reasons, the Board concludes that weight of the evidence is against service connection for a right hip disorder as secondary to the service-connected left ankle or left foot disabilities, and the claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS FOR REMAND Service Connection for an Acquired Psychiatric Disorder The Veteran generally contends that service connection is warranted for PTSD due to witnessing the death of civilians while working as a heavy vehicle driver during service. Specifically, the Veteran contends that she was deployed to Somalia with the 63rd Battalion from January 1993 to May 1993 in support of Operation Restore Hope. The Veteran asserts that in January 1993, while deployed to Somalia, she was driving the last vehicle in a convoy returning to base camp following a recon mission in Mogadishu, Somalia. She reports that Staff Sergeant (Sgt.) Aldridge was the only passenger in the vehicle. The Veteran contends that a Jeep of Pakistani soldiers joined the convoy, falling in line behind her vehicle. The Veteran contends that she noticed three Somalian men walking on the sidewalk during the drive, and that she witnessed the Pakistani soldiers open fire on the Somali civilians unprovoked, resulting in their death. The Veteran contends that she feared for her life in that moment and was subsequently on edge and fearful anytime she left the base camp. See June 2018 Board hearing transcript, see also December 2012 Lay Statement, May 2015 VA Form 9. A November 2012 note from Dr. Yacoub and a July 2013 letter from the Veteran’s treating therapist reflect that the Veteran had a diagnoses of PTSD and depressive disorder and received treatment at the Wilmington, Delaware, Vet Center from December 2012 to April 2013 and the Wilmington VA Medical Center (VAMC). See November 2012 VA treatment record, July 2013 correspondence. A February 2016 Richmond VAMC treatment note reflects that the Veteran also reported a history of treatment for PTSD at a Pennsylvania VAMC and that she expressed intent to resume treatment for PTSD at her local Vet Center. The Veteran testified that she has a current diagnosis of PTSD and is currently in group therapy for PTSD as well. See June 2018 Board hearing transcript. A review of the claims file does not indicate that these records have been obtained; therefore, VA should obtain all relevant VA clinical records pertaining to any psychological or psychiatric treatment for any disorder or symptoms. On remand the Agency of Original Jurisdiction (AOJ) should obtain any outstanding VA treatment records that pertain to treatment of a mental health disorder. In the December 2012 lay statement the Veteran asserted that both she and Staff Sgt. Aldridge were interviewed by CID, that is, U.S. Army Criminal Investigation Command (USACIDC), the morning after the claimed stressful event, as witnesses to the Pakistani soldiers’ attack on the Somali civilians. The Veteran reported that an investigator informed her that a follow up investigation would be conducted. See December 2012 Correspondence. On remand, the AOJ should also attempt to obtain any investigative reports from USCIDC regarding the claimed stressor, as such information may be helpful in verifying a stressor. Service connection for an acquired psychiatric disorder is REMANDED for the following action: 1. Associate with the record all outstanding VA treatment records not already of record, including records from VA Medical Centers and Vet Centers in Wilmington, Delaware, Pennsylvania, and Virginia pertaining to the treatment of any mental health disorder. 2. Request any available investigative report from USACIDC for the period from January 1993 to May 1993 regarding the claimed stressor, i.e., the Veteran and Staff Sgt. Aldridge witnessing an attack on three Somali civilians by Pakistani military forces while deployed to Somalia in support of Operation Restore Hope. J. PARKER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Moore, Associate Counsel