Citation Nr: 21000709 Decision Date: 01/06/21 Archive Date: 01/06/21 DOCKET NO. 15-39 853 DATE: January 6, 2021 REMANDED Entitlement to service connection for a bilateral hip disability, to include as secondary to the service-connected right knee disability, is remanded. Entitlement to service connection for a left knee disability, to include as secondary to the service-connected right knee disability, is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1987 to February 1989. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a March 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The issues were previously before the Board in June 2018 when they were remanded for further development. 1. Entitlement to service connection for a bilateral hip disability, to include as secondary to the service-connected right knee disability The Veteran contends that he suffers from a bilateral hip disability as a result of his service. In the alternative, he claims that his hip disability is secondary to his service-connected right knee disability. The Veteran was provided with a VA examination in July 2019 where he was noted to have diagnoses for bilateral osteoarthritis, right trochanteric pain syndrome, and bilateral degenerative arthritis. The VA examiner opined that the Veteran’s hip disability was less likely than not due to his service because “there is no evidence of any hips conditions, treatments, or diagnosis during service or year thereafter.” The examiner also opined that the Veteran’s hip disability was less likely than not proximately due to his service-connected right knee disability because his right knee disability does “not have any pathophysiologic effect in hips joints.” He added that “there is no leg discrepancies, nor any significant biomechanical derangements in right knee so as to have any effect in hip joints.” The examiner noted that the Veteran’s hip disability “is most likely due to aging process.” The examiner also found that the Veteran’s hip disability, which clearly and unmistakably existed prior to service, was not aggravated beyond its natural progression by his right knee disability because “medical records during service fail to show any treatments during service for any hip conditions.” He added that “conditions in hips appeared years after service.” The Board notes that the Veteran’s March 1987 enlistment examination did not show a pre-existing hip disability and the July 2019 VA examiner did not provide any rationale for the opinion that the Veteran’s hip disability clearly and unmistakably existed prior to service. Accordingly, an addendum medical opinion must be obtained prior to adjudication of this issue. The Board also notes that VA treatment records from August 2019 show that the Veteran was diagnosed with calcific tendinitis of the right hip, mild pelvic enthesopathy, and vascular calcifications of the hips. Upon remand, the medical opinion should also address these diagnoses. 2. Entitlement to service connection for a left knee disability, to include as secondary to the service-connected right knee disability The Veteran contends that he suffers from a left knee disability as a result of his service. In the alternative, he claims that his left knee disability is secondary to his service-connected right knee disability. The evidence of record includes October 2014 private treatment records with MRI results indicating small joint effusion in the left knee. The Veteran was provided with a VA examination in March 2015 where he reported that “weight shift to the left side” due to his service-connected right knee disability “is causing him pain at the left knee joint.” At a July 2019 VA examination, the VA examiner opined that the Veteran’s left knee disability was less likely than not due to his service because there is “no evidence of any left knee conditions during service or year thereafter.” The examiner also opined that the Veteran’s left knee disability was less likely than not proximately due to his service-connected right knee disability because there is “no actual evidence of any left knee conditions.” He added that the Veteran’s left knee disability which clearly and unmistakably existed prior to service, was not aggravated beyond its natural progression by his service-connected right knee disability. In an April 2020 addendum opinion, the VA examiner opined that the Veteran’s left knee disability was less likely than not due to his service because “there is no evidence of any left knee conditions, impairments, or injuries seen during service or year thereafter.” The examiner noted that “evaluation done for both knees in 2015 as well as in 2019 showed an unremarkable left knee in both examinations.” He added that the Veteran “was not complaining from any left knee pain in none of the evaluations done in 2015 and in 2019.” The examiner opined that the Veteran’s left knee disability was less likely than not proximately due to his service-connected right knee disability because “his right knee has not enough loss of range of motion, or instabilities to have any effect in left knee’s anatomy, range of motion, or biomechanics.” The examiner also noted that the Veteran’s left knee disability which clearly and unmistakably existed prior to service was not aggravated beyond its natural progression by his service-connected right knee disability. He noted that the 2014 MRI findings “suggest a physiological effusion and not a pathological condition in the left knee so as to account for any specific injury or impairment.” The examiner added that the Veteran “is actually not complaining from any left knee pain and his physical evaluation was unremarkable in both evaluations (one in 2015 and another one in 2019).” The Board notes that the Veteran’s March 1987 enlistment examination showed normal results for “lower extremities,” and the VA examiner who provided the July 2019 and April 2020 opinions did not provide any rationale for the opinion that the Veteran’s left knee disability clearly and unmistakably existed prior to service. Additionally, the VA examiner who provided the above-mentioned examination reports supported his negative nexus opinions by stating that the Veteran did not report any left knee pain at the March 2015 and July 2019 VA examinations. However, as noted above, the Veteran did in fact complain of left knee pain at the March 2015 VA examination. Additionally, the Board notes that even without a current diagnosis, the symptoms the Veteran describes as pain in his left knee may constitute a current disability to the extent it results in functional impairment of earning capacity. Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). Accordingly, an addendum medical opinion must be obtained prior to adjudication of this issue. If the examiner determines that a diagnosis for a left knee disability is not warranted at any time during the appeal period, the examiner should determine if the Veteran’s symptoms rise to the level of functional impairment of earning capacity. As a final matter, the Board notes that the claims file includes records from the Social Security Administration (SSA) that require translation from Spanish to English. Some of these records have been translated into English, however a complete translation is not of record. On remand, the RO must translate those documents, as well as any additional documents that require translation from Spanish to English and associate all English translations with their respective Spanish originals, in the claims file. The matters are REMANDED for the following action: 1. Obtain English language translations of all documents in the claims file that are in Spanish, to include the SSA records. All English translations must be associated with their respective Spanish originals in the claims file. 2. Arrange for an appropriate health care provider to review the Veteran’s claims file and provide an opinion as to the following: a) Is it at least as likely as not (50 percent probability or greater) that the Veteran’s bilateral hip disability had its onset in service or is otherwise etiologically related to any in-service disease, injury, or event in service? b) Is it at least as likely as not (50 percent probability or greater) that the Veteran’s bilateral hip disability is (1) proximately due to or (2) aggravated beyond its natural progression by the Veteran’s service-connected right knee disability? If the reviewing health care provider finds that physical examination of the Veteran and/or diagnostic testing is necessary, such should be accomplished. In providing the opinion, the examiner should consider i) the fact that the Veteran’s March 1987 enlistment examination does not indicate any existing hip disability, ii) the evidence of record including diagnoses for bilateral osteoarthritis, right trochanteric pain syndrome, bilateral degenerative arthritis, calcific tendinitis of the right hip, mild pelvic enthesopathy, and vascular calcifications of the hips. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 3. Arrange for an appropriate health care provider to review the Veteran’s claims file and provide an opinion as to the following: a) Is it at least as likely as not (50 percent probability or greater) that the Veteran’s left knee disability had its onset in service or is otherwise etiologically related to any in-service disease, injury, or event in service? b) Is it at least as likely as not (50 percent probability or greater) that the Veteran’s left knee disability is (1) proximately due to or (2) aggravated beyond its natural progression by the Veteran’s service-connected right knee disability? If the reviewing health care provider finds that physical examination of the Veteran and/or diagnostic testing is necessary, such should be accomplished. In providing the opinion, the examiner should consider i) the Veteran’s March 1987 enlistment examination showing “normal” results for “lower extremities,” ii) the October 2014 private MRI of the left knee showing small joint effusion, and iii) the March 2015 VA examination noting the Veteran’s symptoms of having pain in his left knee. If the examiner determines that a diagnosis for a left knee disability is not warranted at any time during the appeal period, the examiner should comment on whether the Veteran’s reported symptoms result in functional impairment of the Veteran’s earning capacity. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 4. After undertaking any additional development deemed appropriate and giving the Veteran full opportunity to supplement the record, adjudicate the Veteran’s pending claim in light of any additional evidence added to the record. If any benefit sought on appeal remains denied, the Veteran and his representative should be furnished with a Supplemental Statement of the Case and be afforded the applicable opportunity to respond before the record is returned to the Board for further review. M. Donohue Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Morrad, 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.