Citation Nr: 20009872 Decision Date: 02/05/20 Archive Date: 02/05/20 DOCKET NO. 15-27 287 DATE: February 5, 2020 REMANDED Service connection for a low back disability is remanded. Service connection for a left knee disability is remanded. Service connection for a left shoulder disability is remanded. Service connection for gastroesophageal reflux disease (GERD) is remanded. Service connection for a left wrist disability is remanded. Service connection for a deviated septum is remanded. Service connection for a left hip disability is remanded. Service connection for a right hip disability is remanded. REASONS FOR REMAND The Veteran had active service from March 1974 to June 1994. Initially, it appears that there may be outstanding treatment records from the William Beaumont Army Medical Center (AMC). There are treatment records on file dated from November 12, 2009 to December 14, 2011, and from March 6 – 12, 2019. Any outstanding treatment records dated prior to November 12, 2009, and from December 15, 2011 to March 5, 2019, should be associated with the claims folder. On Remand, associate updated VA treatment records for the period from January 18, 2020, in addition to conducting the development noted below. Low back disability At his Board hearing, the Veteran asserted that there was no back issue and that he had no problems with his back. 12/12/2019 Hearing Transcript at 2. The Veteran, however, did claim service connection for a low back disability, and perfected an appeal with regard to this issue. Service treatment records are negative for a low back disability, but post-service treatment records do reflect treatment related to the low back. Should the Veteran desire to withdraw this issue, such must be done in writing. Otherwise, once outstanding records are associated with the claims folder, such issue will be addressed by the Board. Left knee disability In October 1979, the Veteran sustained a left knee sprain. 05/20/1994 STR-Medical at 42-44. He complained of left knee pain in March 2006 and January 2008. A January 2008 x-ray of the left knee was normal. A February 2009 x-ray examination reflects an assessment of questionable osteoarthritis. 02/28/2012 Medical Treatment Record-Government Facility at 15, 18, 25, 31. An October 2012 VA examination reflects the examiner’s assessment that there was no objective evidence to support a left knee disordewr. 10/25/2012 VA Examination at 20. Subsequent treatment records reflect treatment for a left knee disability, to include a diagnosis of degenerative joint disease of the left knee and a torn medial meniscus shown on MRI. 08/14/2018 CAPRI at 15, 25, 32, 38, 65, 90, 104. In light of the in-service complaints and the post-service diagnosis, an opinion should be sought. Left shoulder disability A May 1994 service treatment record reflects a diagnosis of left shoulder arthritis. 05/20/1944 STR-Medical at 39. An October 2012 VA examination reflects the examiner’s assessment that there is no objective evidence to support a left shoulder condition. 10/25/2012 VA Examination at 40. An April 2013 VA treatment record reflects complaints of left shoulder pain. 08/14/2018 CAPRI at 103. In light of the in-service diagnosis, and the post-service complaints of pain, a further opinion should be sought. GERD The Veteran asserts that he has had GERD since service. An October 2012 VA examination reflects a diagnosis of GERD. The examiner stated that gastrocolitis does not cause GERD, and the Veteran’s cause of “stomach pain” in the right lower quadrant is not associated with GERD. 10/25/2012 VA Examination at 2, 36. Such opinion, however, does not address whether GERD is due to service. An opinion should be sought. Left wrist disability In October 1988, the Veteran sustained a left wrist sprain. 05/20/1944 STR-Medical at 4-6, 84-89. An October 2012 VA examination reflects the examiner’s assessment that there is no objective evidence to support a left wrist condition. Id. at 61. Post-service treatment records do not otherwise reflect a left wrist disability. In order to support the claim, the Veteran should submit or identify medical evidence of a left wrist disability. 38 C.F.R. § 3.303. Deviated septum A November 1995 record reflects complaints of an inability to breath from his nose since breaking his nose many years prior. The assessment was a nasal blockage. 02/28/2012 Medical Treatment Record-Government Facility at 60. The Veteran submitted November 1995 correspondence from T.E.A., M.D., which details his problems with a long history of bilateral nasal airway obstruction. The Veteran reported that the obstruction became apparent after he sustained a blow to his nose in a basketball game during service. He denied a history of sinusitis or known allergies. Upon examination, the physician found that he has a chronic nasal airway obstruction that is both mechanical and physiologic in nature secondary to his septal deviation and hypertrophic turbinate swelling. 11/06/2019 Third Party Correspondence. Subsequent treatment records reflect diagnoses of allergic rhinitis, sinusitis, bronchitis, and pharyngitis. 02/28/2012 Medical Treatment Record-Government Facility at 2, 53, 54, 57; 02/28/2012 at 22, 24, 43-44. Due to the Veteran’s lay assertions of injuring his nose during service and the fact that a chronic nasal airway obstruction was diagnosed less than two years after separation from service, the Veteran should be afforded a VA examination to assess the nature and etiology of his claimed deviated septum. Bilateral hips At the Board hearing, the Veteran testified that he was having no problems with his hips. 12/12/2019 Hearing Transcript at 12. However, he did claim service connection for disabilities of the left and right hips and perfected an appeal with regard to these issues. Service treatment records do reflect complaints of a click in the left hip, but no diagnosis was rendered. 05/20/1994 STR-Medical at 64. Post-service treatment records do not reflect a diagnosis of a right or left hip disability. Should the Veteran desire to withdraw these issues, such must be done in writing. Otherwise, once outstanding records are associated with the claims folder, such issues will be addressed by the Board. The matters are REMANDED for the following actions: 1. Please contact the Veteran and inquire whether he desires to withdraw the issues of service connection for a low back disability, right hip disability, or a left hip disability. If he desires to withdraw his appeal with regard to any of these issues, such must be done in writing. 2. Associate outstanding records from the William Beaumont AMC for the period prior to November 12, 2009, from December 15, 2011 to March 5, 2019, and from March 13, 2019. 3. Associate updated VA treatment records for the period from January 18, 2020. 4. Schedule the Veteran for a VA examination with a clinician with appropriate expertise to determine the nature and etiology of his claimed left knee disability. It is imperative that the claims folder and Virtual folder and a copy of this remand be made available to the examiner in connection with the examination. Any medically indicated special tests should be accomplished, and all special test and clinical findings should be clearly reported. After reviewing the claims file and examining the Veteran, the examiner should opine as to the following: a) Please identify all disabilities of the left knee; Consideration should be given to the diagnoses of record. b) Is a disability of the left knee at least as likely as not (a 50 percent or more probability) due to active service? Please provide a comprehensive rationale for the opinion offered. All pertinent evidence, including both lay and medical, should be considered. The clinician is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. 5. Schedule the Veteran for a VA examination with a clinician with appropriate expertise to determine the nature and etiology of his claimed left shoulder disability. It is imperative that the claims folder and Virtual folder and a copy of this remand be made available to the examiner in connection with the examination. Any medically indicated special tests should be accomplished, and all special test and clinical findings should be clearly reported. After reviewing the claims file and examining the Veteran, the examiner should opine as to the following: a) Please identify all disabilities of the left should; b) Is a disability of the left shoulder at least as likely as not (a 50 percent or more probability) due to active service? Please provide a comprehensive rationale for the opinion offered. All pertinent evidence, including both lay and medical, should be considered. The clinician is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. 6. Schedule the Veteran for a VA examination with a clinician with appropriate expertise to determine the nature and etiology of his claimed GERD. It is imperative that the claims folder and Virtual folder and a copy of this remand be made available to the examiner in connection with the examination. Any medically indicated special tests should be accomplished, and all special test and clinical findings should be clearly reported. After reviewing the claims file and examining the Veteran, the examiner should opine as to whether GERD is at least as likely as not (a 50 percent or more probability) due to active service? Please provide a comprehensive rationale for the opinion offered. All pertinent evidence, including both lay and medical, should be considered. The clinician is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. 7. Schedule the Veteran for a VA examination with a clinician with appropriate expertise to determine the nature and etiology of his claimed deviated septum. It is imperative that the claims folder and Virtual folder and a copy of this remand be made available to the examiner in connection with the examination. Any medically indicated special tests should be accomplished, and all special test and clinical findings should be clearly reported. After reviewing the claims file and examining the Veteran, the examiner should opine as to whether the Veteran’s has a deviated septum that is at least as likely as not (a 50 percent or more probability) due to active service? Please provide a comprehensive rationale for the opinion offered. All pertinent evidence, including both lay and medical, should be considered. The clinician is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. 8. If relevant evidence is received regarding the back and the hips, then schedule an examination to determine whether it is at least as likely as not that any such disabilities are related to active service. Any opinion should be accompanied by a comprehensive rationale. All pertinent evidence, including both lay and medical, should be considered. Eric S. Leboff Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M.W. Kreindler, Counsel 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.