Citation Nr: 21002426 Decision Date: 01/13/21 Archive Date: 01/13/21 DOCKET NO. 17-01 306 DATE: January 13, 2021 REMANDED Entitlement to service connection for a left leg disorder is remanded. REASONS FOR REMAND Entitlement to service connection for a left leg disorder is remanded. The Veteran served during the Gulf War era in the Navy from November 2000 to December 2008. The matter comes to the Board of Veterans’ Appeals (Board) from a decision of the Regional Office (RO) denying service connection for a claimed left leg disability. In February 2020, the Veteran testified before the Board of Veteran’s Appeals (Board) by means of a video conference. A transcript of the testimony is of record in the Veteran’s claims file. The Veteran contends that his left leg disorder is due to injuries incurred during service. At his Board hearing, the Veteran testified that he was injured playing ball and was treated at the Naval Medical Center San Diego. He testified that the condition has worsened since that time. He also testified that sometimes his knee would give out on the ship and towards the end of service he was injured and treated again. The two incidents of treatment the Veteran referenced are reflected in the Veteran’s service treatment records (STR’s). In June 2014, two STR’s were associated with the file: a November 2008 STR reflecting complaints of pain when running and an August 2005 STR reflecting left knee joint pain and hyperextension of the knee after falling when running during a softball game. Also, in June 2014, Dr. V. associated a nexus opinion with the file regarding a left hamstring tear that the Doctor opined was connected to military service. Medical treatment records after service reflect that the Veteran sometimes reports his left leg pain problems as “Injured in service (Navy) from running too hard” and sometimes describes his pain origin as “hip and hamstring”. Although the Board regrets the delay, the Veteran’s claim must be remanded for a VA medical opinion before the Board is able to decide on the merits. The Board finds the (undated) medical nexus opinion from Dr. V. relative to the Veteran’s left hamstring tear to be inadequate because no rationale was provided. (This document was associated with the claims file June 2, 2014). In addition, the Veteran’s statements and treatment reports seem to reflect that there may be more than one left leg medical condition and diagnosis. It is necessary to clarify the nature and etiology of the Veteran’s left leg disorder, and whether or not the disability consists of more than one diagnosis. Treatment records reflect that Dr. V. rendered an opinion with regard to a hamstring tear as a result of military service but the Veteran has sometimes contended that the left leg disability should be characterized as left knee pain, iliotibial band syndrome (ITBS), knee sprain. See Veteran’s statement on the Form 9 submitted December 2016. The VA has a duty to assist claimants and must make “reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the claimant’s claim for benefits.” 38 U.S.C. § 5103A (a)(1). And part of that duty to assist includes obtaining a medical opinion when an “opinion is necessary to make a decision on the claim.” 38 U.S.C. § 5103A (d)(1). The VA must provide a medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) evidence establishing that an event, injury, or disease, occurred in service; (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran’s service or with another service connected disability; but (4) insufficient competent medical evidence on file for the Secretary to make a decision on the claim. 38 U.S.C. § 5103A (d)(2); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Whenever the Board remands a claim for a VA medical examination, as it has done here, the Secretary must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). That includes ensuring the medical opinion addresses the appropriate theories of entitlement. Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007). The record reflects that while in service, the Veteran’s STR’s include left leg complaints in records dated August 2005 and November 2008. In January 2009 the Veteran filed a VA claim for service connection left knee pain and requested a medical exam. Dr. V. associated a nexus opinion (undated) with regard to a left hamstring tear filed in June 2014. Treatment records dated 2010 through 2017 show left hamstring pain, partial tear of the semimembranosus on left hip MRI. February 2013 the Veteran reported leg pain, left hip pain, chronic intermittent pain in the left leg, reproduced with running. In addition, parathesias of coldness and numbness. In August 2010 the Veteran was found to have leg length discrepancy (LLE 1/4 to 1/8 inch longer than RLE). In January 2013 the Veteran was diagnosed with piriformis syndrome. Thus, the record reflects competent evidence of persistent and/or recurrent symptoms of one or more left leg disabilities. The Veteran is entitled to a medical opinion if the elements of 38 U.S.C. § 5103A are met. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Here, the Veteran has provided competent evidence of left leg disorder(s), evidence of in-service injuries, and an indication that his left leg disorder(s) may be associated to those injuries. In addition, there is insufficient evidence in the record to decide on the claim. Thus, the requisite elements of 38 U.S.C. § 5103A have been met. As a result, the Veteran is entitled to a medical opinion that addresses all appropriate theories of entitlement. A remand is required for a medical opinion that addresses all appropriate theories of entitlement to service connection for a left leg disorder. The matters are REMANDED for the following action: 1. Prior to obtaining any opinion, the Veteran’s assistance should be obtained to ensure that copies of any outstanding records of pertinent medical treatment are identified and added to the claims file. Contact the Veteran and with his assistance, identify any outstanding records of pertinent medical treatment from VA or private health care providers. 2. After any additional records are associated with the claims file, afford the Veteran a VA examination with an appropriate specialist to determine the nature and etiology of his left leg disorder(s). The remand and the entire claims file should be made available, reviewed by the examiner, and the examiner should note this was accomplished. Any indicated tests and studies should be undertaken and all clinical findings must be reported in detail and correlated to a specific diagnosis. Please provide an explanation for all opinions expressed. The examiner should identify the nature and etiology of all the Veteran’s current left leg symptoms to determine whether the Veteran suffers from one or more current diagnoses. The examination should include any diagnostic testing or evaluation deemed necessary to identify the claimed disability(s). For each left leg diagnosis identified, the examiner should respond to the following: Is it at least as likely as not (50 percent or greater probability) that any currently diagnosed left leg disability: (a) was caused by, aggravated by, manifested during, or was otherwise related to a period of active duty service; or (b) manifested within one year after discharge from service; or (c) was noted during service with continuity of the same symptomatology since service. The examiner is asked to specifically cite to the evidence in the Veteran’s claims file records, including clinical records, service treatment records (STR’s) and the Veteran’s statements regarding his symptoms. It should be noted that the Veteran, is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a clinical basis to support or doubt the lay history provided by the Veteran, the examiner should provide a fully reasoned explanation. If an opinion cannot be provided without resorting to mere speculation, the examiner should identify all medical and lay evidence considered in reaching the conclusion, fully explain why this is the case, and identify what additional evidence (if any) would allow for a more definitive opinion. A clear explanation for all opinions based on specific facts of the case as well as relevant medical principles is needed. DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M.M. Schneider 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.