Citation Nr: 21005251 Decision Date: 01/29/21 Archive Date: 01/29/21 DOCKET NO. 12-33 076 DATE: January 29, 2021 ORDER New and material evidence having been received, the petition to reopen the claim for service connection for a left hip disability is granted. Entitlement to service connection for a right knee disability is denied. Entitlement to service connection for a left knee disability is denied. REMANDED Entitlement to service connection for a left hip disability, to include on a secondary basis, is remanded. FINDINGS OF FACT 1. A January 2008 Board decision, in pertinent part, denied entitlement to service connection for a left hip disorder. The Veteran did not appeal that decision. 2. Some of the evidence received since January 2008, when considered by itself or in connection with evidence previously assembled, relates to unestablished facts necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claim of service connection for a left hip disability. 3. The Veteran’s right knee disability did not originate in service, within a year of service, and is not otherwise etiologically related to the Veteran’s active service. 4. The Veteran’s left knee disability did not originate in service, within a year of service, and is not otherwise etiologically related to the Veteran’s active service. CONCLUSIONS OF LAW 1. The January 2008 Board decision which, in pertinent part, denied the Veteran’s claim of entitlement to service connection for a left hip disorder is final. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 3.156, 20.201, 20.302, 20.1100. 2. The evidence received since the January 2008 Board decision is new and material, and the claim of entitlement to service connection for a left hip disability is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. The criteria for service connection for a right knee disability have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. 4. The criteria for service connection for a left knee disability have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1987 to September 1991, with additional service in the Army National Guard. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a May 2012 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In January 2018, the Veteran testified at a Board videoconference hearing before the undersigned. A copy of the transcript of that hearing has been associated with the claims file. By way of background, these matters were previously before the Board in April 2018, when they were remanded for additional development. The Board notes that the April 2018 Board remand included the issue of entitlement to service connection for a chronic acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), an anxiety disorder other than PTSD, a depressive disorder, and a substance abuse disorder. See April 2018 BVA Decision. However, during the pendency of the appeal, a March 2020 rating decision granted service connection for PTSD. See March 2020 Rating Decision – Narrative. Accordingly, the issue of entitlement to service connection for a chronic acquired psychiatric disorder is no longer in appellate status as there is no case or controversy presently before the Board. See Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997). Lastly, the Board acknowledges that the September 2020 supplemental statement of the case (SSOC) reopened the claim of entitlement to service connection for avascular necrosis, left hip, but denied the claim based on de novo review of the evidence. As a threshold matter, however, the Board must determine whether new and material evidence has been submitted to reopen a previously denied claim. See Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001); Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). New and Material Evidence 1. New and material evidence having been received, the petition to reopen the claim for service connection for a left hip disability is granted. In order to reopen a claim which has been denied by a final decision, the claimant must present new and material evidence. 38 U.S.C. § 5108. New evidence means existing evidence not previously submitted to VA. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). For purposes of reopening a claim, the credibility of newly submitted evidence is generally presumed. See Justus v. Principi, 3 Vet. App. 510, 513 (1993) (in determining whether evidence is new and material, the “credibility” of newly presented evidence is to be presumed unless the evidence is inherently incredible or beyond the competence of the witness). The language of 38 C.F.R. § 3.156(a) creates a low threshold for finding new and material evidence, and views the phrase “raises a reasonable possibility of substantiating the claim” as “enabling rather than precluding reopening.” Evidence “raises a reasonable possibility of substantiating the claim,” if it would trigger VA’s duty to provide an examination in adjudicating a non-final claim. Shade v. Shinseki, 24 Vet. App. 110 (2010). In January 2008, the Board, in pertinent part, denied the Veteran’s claim for entitlement to service connection for a left hip disorder. Specifically, the Board found that the Veteran’s left hip disorder was not incurred in or aggravated by his active duty service. To this end, the Board determined that there was no medical evidence of record to show that the Veteran had a diagnosed left hip disability prior to December 1999, more than eight years after he was discharged from active duty service. The Board also found that the medical evidence of record showed that the Veteran’s diagnosed left hip disorder was caused by alcohol abuse. Evidence considered at the time of the January 2008 Board decision included VA treatment records dated from August 1999 to December 2003, negative responses to VA requests for records from Tripler Army Hospital, the Alabama National Guard, and the National Personnel Records Center (NPRC), statements from the Veteran and his mother dated in September and December 2003, and a November 2003 hearing transcript. See January 2008 BVA Decision. The Veteran did not appeal the January 2008 Board decision. Accordingly, it is final. The Veteran filed his claim to reopen in June 2011. See June 2011 VA Form 21-526b, Veteran Supplemental Claim. Since the final January 2008 Board decision, VA treatment records, Army National Guard personnel records, lay statements dated in September and October 2011, statements from the Veteran dated in May, June and July 2012, and a January 2018 hearing transcript have been added to the file. During the January 2018 hearing before the Board, the Veteran testified that he jammed his left hip during training exercises. Alternatively, the Veteran reported that he slipped on a patch of ice and landed directly on his tail bone while he was participating in an Orient Shield exercise in 1989. See January 2018 Hearing Transcript, pages 13, 17-18. In addition, the Veteran’s VA treatment records include a February 2013 orthopedic surgery outpatient note, which shows that the Veteran reported that he fell on his hip while he was in the military and stated that he has had pain in his hip since the in-service incident. See August 2016 CAPRI. This evidence is new and material because it was not of record at the time of the final Board decision in January 2008, and indicates that the Veteran has a current left hip disability which may be related to his active duty service. The Board finds this evidence would trigger VA’s duty to provide an examination in adjudicating a non-final claim. Accordingly, the Board finds this new evidence raises a reasonable possibility of substantiating the Veteran’s claim of entitlement to service connection for a left hip disability, and as such, the claim is now reopened. See Shade, 24 Vet. App. at 110. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. In order to establish entitlement to service connection, there must be (1) evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) a causal connection between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may be presumed for certain chronic diseases which develop to a compensable degree within one year after discharge from service, even though there is no evidence of the disease during the period of service. That presumption is rebuttable by probative evidence to the contrary. 38 U.S.C. §§ 1101, 1137; 38 C.F.R. §§ 3.307, 3.309(a). The Board must determine whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either case, or whether the preponderance of the evidence is against the claim, in which case, service connection must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to service connection for a right knee disability is denied. 3. Entitlement to service connection for a left knee disability is denied. During the January 2018 Board hearing, the Veteran testified that he jammed his left knee during light private training and stated that he has experienced progressive knee pain since the in-service incident. In this regard, the Veteran testified that he did not report knee pain during service because the pain was small, and he was afraid that he would not be discharged if he reported the injury. The Veteran further testified that he initially sought treatment when his knee pain became constant, approximately two years after he was discharged from active duty service, and denied any post-service traumatic falls. Alternatively, the Veteran testified that his current knee injuries may have been caused by wear and tear from carrying an M60 machine gun and his ruck sack on monthly road marches over mountainous terrain. See January 2018 Hearing Transcript, pages 2-13, 17. In addition, in his January 2012 supplemental claim, the Veteran stated that his bilateral knee disability may have been caused by his left hip disability, and a September 2003 contact note shows that the Veteran stated that his current knee disability may have been caused by trichomonas, a tropical disease that he contracted while he was serving in Thailand. See January 2012 VA Form 21-526b, Veteran Supplemental Claim; September 2003 VA memorandum. In support of his claim, the Veteran submitted letters from his mother and a friend, received in December 2003 and February 2012, which state that the Veteran reported that he injured his hip and knee after he fell during service. The letters further state that the Veteran sought medical treatment for his knee injury during service. See October 2003 Third Party Correspondence; February 2012 VA Form 21-4138 Statement in Support of Claim. The Veteran also submitted a statement from a fellow service member, dated in October 2011, which supports the Veteran’s assertion that he fell on a road march, injuring his hip and knee. She further stated that the Veteran was initially prescribed bed rest and was later placed on light duty by the physician who treated him. See February 2012 VA Form 21-4138 Statement in Support of Claim. The Board notes that almost all of the Veteran’s service treatment records (STRs) are unavailable, and that his available service personnel records (SPRs) are very limited. See November 1996 Administrative Decision; December 2002 VA Memorandum; May 2016 VA Memorandum. When service records are incomplete, the Board has a heightened obligation to explain its findings and conclusions and carefully consider the benefit-of-the-doubt rule. See Cuevas v. Principi, 3 Vet. App. 542, 548 (1992); O’Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). However, the case law does not lower the legal standard for proving a claim of service connection, but rather increases the Board’s obligation to evaluate and discuss in its decision all of the evidence that may be favorable to the Veteran. See Russo v. Brown, 9 Vet. App. 46 (1996). Moreover, there is no presumption, either in favor of the claimant or against VA, arising from missing records. See Cromer v. Nicholson, 19 Vet. App. 215, 217-18 (2005) (wherein the Court declined to apply an “adverse presumption” where records have been lost or destroyed while in government control which would have required VA to disprove a claimant’s allegation of injury or disease). The Veteran’s STRs do include an August 1987 enlistment report of medical examination that notes the Veteran’s lower extremities to be normal. See August 2016 DPRIS Response. A review of the post-service treatment records shows that the Veteran underwent a bone scan for left hip pain in January 2001, which revealed degenerative changes in both of his knees. See February 2001 Medical Treatment Record – Government Facility. A May 2001 rehabilitation services general medical assessment shows that the Veteran had degenerative joint disorder in his knees. During the assessment, the rehabilitation services examiner noted that the Veteran fell into a gulch during service. See February 2003 Medical Treatment Record – Non-Government Facility. Thereafter, the Veteran denied arthritis, rheumatism, and bursitis and bone, joint, or other deformity on a February 2003 pre-employment physical report of medical history, but the examiner noted that the Veteran had a history of arthritis in his bilateral knees. See February 2003 Medical Treatment Record – Government Facility. The Veteran underwent a VA general medical examination in February 2004. During the examination, the Veteran stated that he had been experiencing problems with his knees for several years. He further reported that an x-ray of his knees conducted in or around 2001 revealed degenerative joint disease. An x-ray of the Veteran’s knees obtained in conjunction with the examination revealed mild narrowing of the medial knee joint compartment bilaterally, and the final diagnosis included degenerative joint disease of the bilateral knees. See February 2004 VA examination. The Veteran was afforded a VA examination for knee and lower leg conditions in December 2018. The examiner noted that the Veteran had been diagnosed with bilateral degenerative arthritis. During the examination, the Veteran reported that his bilateral knee pain manifested in 1989, while he was serving on active duty. Specifically, the Veteran reported that he fell into a hole while carrying out an operation in “light fighters” and injured his left knee. The Veteran reported that he was removed from the site at that time and stated that his symptoms had progressively worsened since the initial injury. The Veteran also endorsed flare-ups and stated that he was not able to continue to stand after long periods of time. After performing an examination and reviewing the evidence of record, the examiner opined that it was less likely than not that the Veteran's bilateral knee disability was incurred in or caused by the claimed in-service injury, event, or illness. In support of her opinion, the examiner noted that the Veteran's service treatment records did not contain complaints, treatments, or diagnoses of right knee degenerative arthritis. The examiner further noted that the Veteran was diagnosed with degenerative changes to the knees following a bone scan of the hips in 2001 and x-rays of the knees in 2003. In this regard, the examiner noted that degenerative arthritis of the knees is a chronic condition that tends to progressively worsen over time with the natural aging process and/or due to repetitive injury. Thus, as there was nothing in the STRs to indicate that the Veteran was seen for such condition, the examiner found that there was no medical evidence to show that the Veteran's bilateral knee disability was related to or had its onset during his active duty service. See January 2019 C&P examination. VA obtained an addendum medical opinion in September 2020. After performing a review of the evidence of record, the examiner opined that it was less likely than not that the Veteran’s bilateral knee disability was incurred in or caused by the claimed in-service injury, event, or illness. In this regard, the examiner acknowledged the Veteran’s reports that he fell into a hole and injured his left knee during service and noted that the STRs present in the claims file were illegible. The examiner further noted that the Veteran was diagnosed with degenerative joint disease of his bilateral knees in 2001, though x-ray images confirming bilateral knee arthritis were not obtained until 2004. However, the examiner found that the Veteran did not report knee pain after he was discharged from service, as would be consistent with the Veteran’s knee pain being related to overuse, wear, and tear from carrying an M60 machine gun and ruck sack, and that no history was noted for any claimed exposure to an infectious disease in Thailand. Rather, the examiner found that the Veteran initially endorsed knee pain in or around 2003 or 2004, approximately 12 or 13 years after he was discharged from service. In this regard, the examiner noted that the Veteran had been involved in multiple altercations since service and may have injured his knees after his discharge but before his initial diagnosis. Therefore, the examiner opined that it was less likely than not that the Veteran’s claimed bilateral knee disability had its onset during service or was related to wear and tear from carrying an M60 machine gun and rucksack or to exposure to an infectious disease in Thailand. See September 2020 C&P examination. After a review of the evidence of record, the Board finds that service connection for a bilateral knee disability is not warranted. In the present case, there is sufficient evidence that the Veteran meets the threshold criterion for service connection of a current disability. Boyer v. West, 210 F.3d 1351 (Fed. Cir. 2000). Specifically, the December 2018 VA examiner noted that the Veteran had been diagnosed with bilateral degenerative arthritis. Accordingly, the remaining question is whether the Veteran’s diagnosed bilateral knee disability is related to service. Concerning the second element of service connection, the Board notes that some of the Veteran’s STRs are unavailable, and that his SPRs are limited. See November 1996 Administrative Decision; December 2002 VA Memorandum; May 2016 VA Memorandum. In this case, the Board finds the Veteran’s reports, when considered in conjunction with statements from the Veteran’s mother, friend, fellow service member, credible and concedes the Veteran experienced left knee pain in service after he fell during a training exercise. See October 2003 Third Party Correspondence; February 2012 VA Form 21-4138 Statement in Support of Claim; January 2018 Hearing Transcript, pages 3-5, 17. The Board acknowledges that the Veteran has made inconsistent statements regarding whether he sought treatment for his knee injury during service. In this regard, the Veteran asserted that he had to be removed from the site of his knee injury during his December 2018 VA examination. See January 2019 C&P examination. However, during his January 2018 Board hearing, the Veteran testified that he did not report knee pain during service because the pain was small, and he was afraid that he would not be discharged if he reported the injury. He further testified that he was young and recovered from his in-service knee injury. See January 2018 Hearing Transcript, pages 3, 9. Importantly, the Board notes that the Veteran’s mother, fellow service member, and friend all reported that the Veteran sought treatment for his knee injury during service in their December 2003, October 2011, and February 2012 statements. See October 2003 Third Party Correspondence; February 2012 VA Form 21-4138 Statement in Support of Claim. The Board recognizes that the Veteran is competent to report that he injured his knee during a training exercise and that he required some type of medical treatment thereafter, despite the fact that his reports during the appeal period have been inconsistent. Layno v. Brown, 6 Vet. App. 465, 470-71 (1994) (Lay testimony is competent evidence insofar as it relates to symptoms of an injury or illness.). Thus, when considered in conjunction with statements from the Veteran’s mother, fellow service member, and friend and after resolving reasonable doubt in the Veteran’s favor, the Board also concedes that the Veteran likely received some treatment for left knee pain during service. As such, the Board finds that the second Shedden requirement for service connection has been satisfied. As to whether the Veteran’s current bilateral knee disability is related to service, the Board finds the September 2020 VA addendum opinion to be the most probative evidence of record. In this regard, the Board finds the December 2018 VA medical opinion to be inadequate as it was based, at least in part, on an incomplete or inaccurate factual premise. Specifically, the December 2018 VA examiner based her opinion on the absence of complaints, treatment, or diagnoses of right or left knee degenerative arthritis in the Veteran’s STRs. To this end, the examiner found that there was nothing in the STRs to indicate that the Veteran was seen for a knee condition in service and, as a result, found that there was no medical evidence to show that the Veteran’s bilateral knee disability was related to or had its onset during his active duty service. See January 2019 C&P examination. However, as noted above, most of the Veteran’s STRs are not associated with the evidentiary record and have been deemed unavailable by VA. In addition, the December 2018 VA examiner did not address the Veteran’s credible statements that he fell during a training exercise, injuring his knee, and subsequently received some treatment for left knee pain. Thus, the Board finds that the December 2018 VA medical opinion is based, at least in part, on an incomplete and inaccurate factual premise, and as such, is currently inadequate to adjudicate the issues on appeal. See Reonal v. Brown, 5 Vet. 458, 461 (1993) (medical opinions based on an incomplete or inaccurate factual premise are not probative); see also Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007) (holding that a VA opinion was inadequate where the examiner did not comment on the Veteran's report of in-service injury and relied on lack of evidence in service medical records to provide a negative opinion). In contrast, the Board finds the September 2020 VA opinion to be the most probative evidence of record. In this regard, after performing a review of the evidence of record, the examiner opined that it was less likely than not that the Veteran’s bilateral knee disability was incurred in or caused by the claimed in-service injury, event, or illness. In support of her opinion, the examiner noted that the Veteran was diagnosed with degenerative joint disease of his bilateral knees in 2001, though x-ray images confirming bilateral knee arthritis were not obtained until 2004, and he initially endorsed knee pain in or around 2003 or 2004, approximately 12 or 13 years after he was discharged from service. In this regard, the examiner noted that the Veteran had been involved in multiple altercations since service and may have injured his knees after his discharge but before his initial diagnosis. Thus, the examiner opined that it was less likely than not that the Veteran’s claimed degenerative joint disease of the bilateral knees had its onset during service or was related to wear and tear from carrying an M60 machine gun and rucksack or to exposure to an infectious disease in Thailand. See September 2020 C&P examination. The Board finds that the September 2020 VA examiner’s opinion was based on a thorough review of the record, is supported by a reasoned analysis of medical facts, and is consistent with the evidence of record. Barr v. Nicholson, 21 Vet. App. 303 (2007); Stefl v. Nicholson, 21 Vet. App. 120 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board acknowledges the Veteran’s assertion that he has been experiencing progressive knee pain since service and initially sought treatment for knee pain approximately two years after he was discharged from active duty. See January 2018 Hearing Transcript, page 3. However, the Board finds that the most probative evidence of record reflects that the Veteran did not report knee pain until many years after his separation from service. In this regard, the evidence of record shows that the Veteran began receiving treatment at VA in February 1996. At that time, the Veteran received treatment for substance abuse, but denied any other medical problems. See September 1996 VA Form 10-1000 Hospital Summary and/or the Compensation and Pension Examination Report. The Board notes that the Veteran continued to receive treatment through VA thereafter, but no complaints, treatment or diagnoses for any knee disabilities were found until the Veteran’s January 2001 bone scan, which was obtained to address the Veteran’s complaints of left hip pain. See July 2020 CAPRI; February 2001 Medical Treatment Record – Government Facility. In addition, the Board emphasizes that the Veteran testified that he initially received treatment for his knee disability from VA during his January 2018 hearing. See January 2018 Hearing Transcript, pages 9-10. It stands to reason that if the Veteran had been experiencing knee pain since service, he would have reported such to his providers, as he had reported other ailments, and such would have been documented in the treatment records. Thus, the Board finds that the medical evidence of record weighs against the credibility of the Veteran’s assertions that he has been experiencing knee pain since service and that he initially sought treatment for his bilateral knee disability in or around 1993/94. See Gardin v. Shinseki, 613 F.3d 1374, 1380 (Fed. Cir. 2010) (upholding Board finding that inconsistent lay statements were not credible because they were in direct contradiction to the more credible, competent, reliable, and clearly documented medical evidence). As such, the Board finds that the absence of reports or findings related to the Veteran’s knee disability until January 2001, or approximately 10 years after his separation from service, considered in conjunction with the presence of medical records showing that the Veteran has been receiving treatment on a regular basis since 1996, but did not report or seek treatment for his knees until many years after separation, to be more probative than the Veteran’s assertions that he has been experiencing symptoms since service. In addition, the Board recognizes that the medical opinions of record do not address whether the Veteran’s bilateral knee disability is etiologically related to his hip disability. However, the Board finds that there is no competent evidence showing that the Veteran’s bilateral knee disability may be related to his current hip disability. As such, the Board finds that the Veteran’s claim does not meet the low threshold requirements of McLendon, and therefore VA’s duty to provide an examination has not been triggered. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); see also Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010) (explaining that something more than conclusory, generalized statements is needed to trigger the VA’s duty to assist); Duenas v. Principi, 18 Vet. App. 512, 517 (2004). The Board further acknowledges the statements from the Veteran and his mother, asserting that his claimed bilateral knee disorder is related to his active duty service. However, the question of whether such a relationship exists is a complex medical issue that is far beyond the purview of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (2007) (providing that the question of whether lay evidence is competent and sufficient is an issue of fact that is to be addressed by the Board); Layno v. Brown, 6 Vet. App. 465, 469 (1994) (noting that personal knowledge is “that which comes to the witness through the use of his senses-that which is heard, felt, seen, smelled, or tasted”). Therefore, to the extent the Veteran is alleging that his current bilateral knee disability is related to service, the Board concludes that the lay assertions in the present case are outweighed by the medical evidence of record, to include the September 2020 VA medical opinion. In this regard, the Board finds that the September 2020 VA examiner has training, knowledge, and expertise on which she relied to form her opinion and provided a persuasive rationale. Importantly, there is no medical evidence to the contrary. Accordingly, the Board finds that the third Shedden requirement has not been met. Although the Veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit-of-the-doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claims for entitlement to service connection for a right knee disability and a left knee disability. The claims are denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 58 (1990). REASONS FOR REMAND Entitlement to service connection for a left hip disorder, to include on a secondary basis, is remanded. During his January 2018 hearing, the Veteran testified that his current hip disability may have been caused by trichomonas, a tropical disease that he contracted while he was serving in Thailand. In this regard, the Veteran stated that his treating physician told him that trichomonas could cause him to develop cancer in his hip later in life. Alternatively, the Veteran testified that his current hip disability may have been caused by injuries he sustained while he was serving on active duty. Specifically, the Veteran testified that he jammed and bruised his left hip during light private training exercises. He further reported that he slipped on a patch of ice and landed directly on his tail bone while participating in an Orient Shield exercise in 1989. See January 2018 Hearing Transcript, pages 11-18. A review of the post-service treatment records shows that the Veteran was provisionally diagnosed with avascular necrosis of the left femoral head in January 2001, which was subsequently confirmed by MRI in December 2001. See April 2001 Medical Treatment Record – Government Facility; April 2002 CAPRI. Thereafter, progress notes dated in April and July 2002 show that the Veteran had been diagnosed with left hip avascular necrosis secondary to his previous history of alcohol abuse as well as a history of sickle cell trait. See November 2002 Medical Treatment Record – Government Facility; November 2002 CAPRI. The Board notes that a March 2020 rating decision granted the Veteran’s claim of entitlement to service connection for PTSD related to an in-service sexual assault. See March 2020 Rating Decision – Narrative. In this regard, the Board notes that the Veteran testified that he turned to drugs and alcohol to mask feelings of anger, bitterness, and resentment related to in-service sexual assault during his January 2018 hearing. See January 2018 Hearing Transcript, page 23. In addition, a March 2017 social work outpatient note shows that the Veteran’s mental disorder diagnoses included PTSD related to sexual trauma, depression, (cannabis dependency, alcohol dependency, polysubstance dependency) in remission, and the Veteran endorsed severe addiction problems, to include “crack, alcohol, and other drugs” from the ages of 25 to 30 during a December 2018 VA PTSD examination. See May 2020 CAPRI. The Board finds that the Veteran should be afforded a VA examination with respect to his claim for entitlement to service connection for a left hip disability. Under McLendon, VA is obligated to provide an examination when the record contains (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, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran’s service, but (4) there is insufficient competent medical evidence on file to decide the claim. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). The Board notes that there is no medical opinion of record as to whether the Veteran has a left hip disability related to service. Accordingly, as the evidence of record shows a diagnosis for avascular necrosis, which the Veteran relates to knee injuries he sustained during service and exposure to trichomonas in Thailand, the Board finds that a VA examination is necessary to determine the nature and etiology of the condition. The Board further notes that there is no medical opinion of record as to whether the Veteran’s left hip disability may have been caused or aggravated by his service-connected PTSD. Thus, the Board finds that a VA opinion is required in order to obtain an opinion addressing the nature and etiology of any current left hip disability. See McLendon, 20 Vet. App. at 81. The matter is REMANDED for the following action: 1. With any necessary identification of sources by the Veteran, request all VA treatment records not already associated with the file from the Veteran’s VA treatment facilities, and all private treatment records from the Veteran not already associated with the file. 2. After completion of the above development, schedule the Veteran for a VA examination by an appropriately qualified examiner to determine the nature and etiology of any current left hip disability, to include avascular necrosis. The examiner should provide the following opinions: (a.) Is it at least as likely as not (50 percent probability or greater) that any currently diagnosed left hip disability is related to the Veteran’s military service, to include as due to the wear and tear of military service, and exposure to trichomonas in Thailand? Please explain why or why not. Please consider the Veteran’s testimony that his treating physician told him that trichomonas could cause him to develop cancer in his hip later in life. (b.) Is it at least as likely as not (50 percent or greater probability) that any currently diagnosed left hip disability was (i) caused or (ii) aggravated by his service-connected PTSD, to include as due to substance abuse (drugs and alcohol) related to the Veteran’s PTSD? Please explain why or why not. If aggravation is found, the examiner should identify, to the extent possible, the baseline level of disability prior to the aggravation and determine what degree of additional impairment is attributable to the Veteran’s service-connected PTSD. The examiner should review the Veteran’s claims file in connection with the opinion. Reasons should be provided for any opinion rendered. If the examiner is unable to provide an opinion without resort to speculation, an explanation as to why this is so should be provided and any additional evidence that would be necessary before an opinion could be rendered should be identified. S. HENEKS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Justis, Attorney-Advisor 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.