Citation Nr: 20008367 Decision Date: 01/31/20 Archive Date: 01/31/20 DOCKET NO. 16-08 352 DATE: January 31, 2020 REMANDED Issue of entitlement to service connection for a low back disability is remanded. Issue of entitlement to service connection for a left hip disability is remanded. Issue of entitlement to service connection for a left leg disability, claimed as a leg length discrepancy is remanded. REASONS FOR REMAND The Veteran had active duty from May 1957 to November 1958. This appeal to the Board of Veterans’ Appeals (Board) arose from a September 2014 rating decision issued by the Department of Veterans Affairs (VA). See October 2014 Notice of Disagreement (NOD); December 2015 Statement of the Case (SOC); February 2016 Substantive Appeal (VA Form 9). The Veteran testified before the undersigned Veterans Law Judge in a November 2017 hearing. See November 2017 Hearing transcript. In February 2018, the Board found that there was new and material evidence to warrant reopening the Veteran’s prior finally disallowed claims of entitlement to service connection for a left leg disability and a left hip disability. February 2018 Board decision. The Board remanded the issues of entitlement to service connection for a low back disability, a left leg disability, and a left hip disability for the Agency of Original Jurisdiction (AOJ) to attempt to obtain any available treatment records from the Memphis VA Medical Center since 1958 that is not already part of the record. Id. The Board finds that there has been substantial compliance with its remand directive. See September 2019 VA Form 10 7131. The appeal is now back before the Board. This appeal has been advanced on the Board’s docket pursuant to 38 C.F.R. § 20.900(c). 38 U.S.C. § 7107(a)(2). 1. Issue of entitlement to service connection for a low back disability is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for a low back disability because no VA examiner has opined on whether the evidence supports a medical link between the Veteran’s current low back disability and service. Lumbar spine imaging evidence shows the Veteran has or has had status post multi-level laminectomy, diffuse disc bulge at L4-5 and L5-S1, anterior listhesis at L4-L5, and pars defect at L4-L5. See April 2003 VA treatment evidence; April 2016 VA treatment evidence. The Veteran testified that he injured his back playing football during service and related to seeking treatment at sick call. See October 2014 NOD; November 2017 Hearing transcript. Unfortunately, the Veteran’s complete service records are unavailable because they may have been destroyed in a fire. March 2002 Correspondence from the National Personnel Records Center. The Board finds that the Veteran should be afforded the opportunity for a VA examination to determine if there is a medical link between his current disability and service. 2. Issue of entitlement to service connection for a left hip disability is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for a left hip disability because no VA examiner has opined on whether the evidence supports a medical link between the Veteran’s current left hip disability and service. Imaging evidence supports that the Veteran was diagnosed with mild left hip arthritis. May 2016 VA treatment evidence. As discussed above, the Veteran’s complete service records are, unfortunately, unavailable because they may have been destroyed in a fire. March 2002 Correspondence from the National Personnel Records Center. However, the Veteran testified that he also injured his left hip while playing football during service. See October 2014 NOD; November 2017 Hearing transcript. The Board finds that the Veteran should be afforded the opportunity for a VA examination to determine if there is a medical link between his current left hip disability and service 3. Issue of entitlement to service connection for a left leg disability, claimed as a leg length discrepancy, is remanded. Finally, because a decision on the remanded issue of entitlement to service connection for a left hip disability could significantly impact a decision on the issue of service connection for a left leg condition, the issues are inextricably intertwined. The Veteran testified that he injured his left hip while playing football in service and this ultimately cause the defect in his leg. See November 2017 Hearing transcript. The Board finds that this claim, thus, requires remand as well. In addition, the Board notes that the Veteran has previously asserted that this his left hip condition was secondary to his left leg condition, and that his left leg condition was the disability due to service. See October 2014 NOD. The Board finds that an opinion from a VA examiner is also needed as to whether there is a medical link between the Veteran’s left leg condition, claimed as leg length discrepancy, and service. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination by an appropriate medical professional to determine the nature and cause of any low back disability. The medical professional should respond to the following: (a) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran’s low back disability began in (or is otherwise related to) the Veteran’s military service? The examiner should consider and discuss the Veteran’s lay testimony and assertions regarding any pertinent complaints and symptoms, including that he injured his back in a football game during service. A detailed explanation (rationale) is requested, including citing to supporting clinical data (and/or medical literature), as appropriate. (b) If the Veteran’s low back disability is deemed to be unrelated to service, the examiner should, if possible, identify the cause considered more likely and explained why that is so. 2. Schedule the Veteran for a VA examination by an appropriate medical professional to determine the nature and cause of any left hip condition, to specifically include mild arthritis of the left hip. The medical professional should respond to the following: (a) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran’s left hip condition began in (or is otherwise related to) the Veteran’s military service? The examiner should consider and discuss the Veteran’s lay testimony and assertions regarding any pertinent complaints and symptoms, to specifically include his statement that he injured his left hip in a football game during service. A detailed explanation (rationale) is requested, including citing to supporting clinical data (and/or medical literature), as appropriate. (b) If the Veteran’s leg hip condition is deemed to be unrelated to service, the examiner should, if possible, identify the cause considered more likely and explained why that is so. (c) The VA examiner should also opine on whether the Veteran has a left hip condition that is proximately due to, the result of, or aggravated by his left leg length discrepancy. 3. Schedule the Veteran for a VA examination by an appropriate medical professional to determine the nature and cause of any left leg condition, to specifically include left leg length discrepancy. The medical professional should respond to the following: (a) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran’s left leg condition began in (or is otherwise related to) the Veteran’s military service? The examiner should consider and discuss the Veteran’s lay testimony and assertions regarding any pertinent complaints and symptoms, to specifically include his statement that he had left leg problems in service. A detailed explanation (rationale) is requested, including citing to supporting clinical data (and/or medical literature), as appropriate. (b) If the Veteran’s left leg condition is deemed to be unrelated to service, the examiner should, if possible, identify the cause considered more likely and explained why that is so. (c) The VA examiner should also opine on whether the Veteran has a left leg condition that is proximately due to, the result of, or aggravated by his left hip arthritis. 4. Review the record and ensure that all development sought in this remand has been completed. Arrange for any further development indicated by the results of the development requested above if deemed warranted by the Agency of Original Jurisdiction (AOJ), and re-adjudicate the claims. If a claim is denied, supply the Veteran and his representative with a supplemental statement of the case and allow an appropriate period of time for response. Thereafter, the claims folder should be returned to the Board for further appellate review, if otherwise in order. DEBORAH W. SINGLETON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Department of Veterans Affairs The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.