Citation Nr: 21064053 Decision Date: 10/18/21 Archive Date: 10/18/21 DOCKET NO. 18-09 585 DATE: October 18, 2021 REMANDED Entitlement to service connection for a left knee disability, to include as due to a service-connected right hip disability and a bilateral ankle disability, is remanded. Entitlement to service connection for a back disability, to include as due to a service-connected right hip disability and a bilateral ankle disability, is remanded. Entitlement to service connection for a left hip disability, to include as due to a service-connected right hip disability and a bilateral ankle disability, is remanded. REASONS FOR REMAND The Veteran had active service from April 1974 to April 1994. These matters are on appeal from an April 2016 rating decision by a Department of Veterans Affairs (VA) regional office (RO). The Veteran had a hearing before the undersigned Veterans Law Judge in March 2021. A transcript has been associated with the file. These matters were previously before the Board and were remanded for further development in May 2021. The development has been completed and the matters are again before the Board. The Board regrets the delay but finds another remand is warranted in the Veteran's claims. The Veteran had a hearing in March 2021. The Veteran said while in service, he worked with mortars and was in the infantry, carrying heavy equipment and marching. The Veteran said he hurt his left knee while carrying heavy equipment over a hill and felt it just pop out of place. His knee was wrapped and he continued on in the field. The Veteran said he also hurt his left knee and back loading and unloading ammunition. The Veteran said the wear and tear of 20 years of service, carrying rucks, lifting heavy things, caused his conditions. Since he left service, the Veteran said he had been getting treatment for his back, including seeing a massage therapist and getting acupuncture. The Veteran has been diagnosed with both back and left knee disabilities. (See e.g. March 2016 examinations.) A June 2017 examiner noted bursitis in both hips. This diagnosis was again noted in a December 2017 examination. A March 2016 examiner opined it was less likely than not the Veteran's left knee condition was proximately due ot his right hip disability. However, in the explanation, the examiner said there was no known causative nexus relationship between one knee bursitis causing the other knee bursitis. The examiner also explained it was less likely than not the Veteran's back disability was due to his right hip, saying there was no known causative nexus relationship between right hip bursitis and progressive spine degenerative joint disease (DJD) or muscle strain. A March 2016 examiner opined it was less likely than not the Veteran's left hip bursitis was due to his right hip bursitis, explaining that the specific cause of hip bursitis was unknown, but there are no objective studies that show causation between one hip bursitis causing another. The Veteran had examinations for his back and knees in December 2017. The examiner saw the Veteran in person, reviewed his file, noted his back and knee diagnoses. The examiner opined it was less likely than not the Veteran's back was incurred in or due to his time in service. The examiner explained the medical records didn't support the Veteran's back strain or degenerative disc disease were incurred in or caused by the wear and tear due to time in service, to include as due to his duties in the infantry or Vulcan crewmembers. This examiner noted the complaint in 1977 of back pain and noted there was no complaints of back pain on the January 1994 separation exam. The examiner did not note the other notations of back pain in the Veteran's STRs. However, it was noted the Veteran did not have back pain on his last examination while in service, his separation examination. The examiner also opined it was less likely than not the Veteran's left knee condition was proximately due to his service-connected right hip disability. The examiner explained that there was no nexus between the two conditions. In accordance with the remand instructions, the Veteran was provided another examination for his back in July 2021. The examiner reviewed the Veteran's file and saw the Veteran in person. The Veteran had an examination for his left knee in July 2021. The examiner noted the Veteran's report that his knee was due to his training and from 20 years of being in the infantry. The examiner noted the Veteran had been diagnosed with a left knee disability. The examiner noted the Veteran's many back diagnoses and noted the Veteran's statements that his pain began around 1976 from running, rucking, and riding in vehicles while in service. The examiner opined it was less likely than not the Veteran's left knee was incurred in or caused by his time in service. The examiner also opined it was less likely than not the Veteran's left knee was proximately due to or the result of his right hip disability. The examiner explained there was no evidence of a left knee injury while in service. The examiner also stated the Veteran did not currently have a diagnosis of bursitis and the currently diagnosed left tibial plateau fracture was secondary to his motor vehicle accident in 2010 at which time, he also had an MCL tear which led to ACL insufficiency and meniscal tear which was seen on MRI in 2017. These conditions were what led to the total knee replacement in 2018 for which the Veteran continued to have instability. The examiner opined it was less likely than not the Veteran's back disability was incurred in or due to his time in service. The examiner also opined it was less likely than not the Veteran's back condition was proximately due to or the result of his right hip disability. The examiner noted November 1977 records showed the Veteran had back pain for two days from "messing around with his dog" and he was diagnosed with a muscle strain. There were no further records showing back problems and the injury and diagnosis were not "consistent with the development of a chronic condition." Additionally, MRI imaging from 2014 showed arthritis typical of age. While the July 2021 examiner did not explicitly say that the Veteran's conditions were not proximately due to or aggravated by his right hip disability in his rationale, the examiner made it clear that the Veteran's conditions were not related to his right hip in any way, offering alternative, more likely causes of his left knee and back disabilities. The Veteran had an examination for his left hip in July 2021. The examiner reviewed the Veteran's file and saw him in person. The examiner reported the Veteran did not currently have a diagnosed left hip disability. The examiner recounted the Veteran's statements of how he injured his hip while in service due to the demands of being in the infantry for 20 years. The July 2021 examiner opined the Veteran's left hip condition was less likely than not incurred during the Veteran's time in service or caused by his hip. The examiner explained there was no evidence a left hip condition happened in service and imaging performed in 2011 and 2017 didn't show any arthritis in the left hip. The examiner reported that the symptoms and signs of the Veteran's condition shown at examination were more consistently diagnosed as piriformis syndrome which was "outside the scope of this exam." However, the Board finds this examination to be inadequate because the examiner did not address the fact the Veteran was previously diagnosed with left hip bursitis. It is also unclear when the Veteran said that the Veteran's condition was more consist with piriformis syndrome if the examiner was saying that rather than having left hip bursitis, the examiner found that the previous diagnoses were inaccurate or if the examiner was simply saying the Veteran did not have left hip bursitis. Either way, a clarification is needed as to what left hip diagnosis the Veteran has, if any, and if it is related to his time in service or proximately due to or aggravated by his service-connected right hip. Additionally, in his March 2021 hearing, the Veteran raised another theory of entitlement: that all of his claimed conditions are secondary to his service-connected bilateral ankle disability. None of the examiners have addressed this theory of entitlement. Therefore, another remand is warranted. Barr v. Nicholson, 21 Vet. App. 303 (2007). The matters are REMANDED for the following action: 1. The AOJ should obtain the Veteran's outstanding medical records and associate them with the claims file. If possible, the Veteran should submit any pertinent new evidence regarding the condition at issue in order to expedite the claim. 2. Schedule the Veteran for an appropriate examination for his 1) left hip disability, his 2) back disability, and his 3) left knee disability. For each claimed disability, the examiner should opine as to the following: (a) The examiner should clearly state what diagnoses the Veteran has. If the examiner finds the Veteran does not have a left hip disability, s/he must explain medical treatment records and examinations showing otherwise. (b) Whether the Veteran's disability was at least as likely as not incurred in and due to his time in service. (c) Whether the Veteran's disability is proximately due to any of his service connected disabilities, to include his right hip and bilateral ankle disabilities. (d) Whether the Veteran's disability is aggravated by any of his service connected disabilities, to include his right hip and bilateral ankle disabilities. NOTE: "Aggravation" does not mean a permanent worsening. Any temporary or incremental worsening is sufficient for a finding of "aggravation." The examiner must account for the Veteran's statements including about what occurred during his time in service and his continuing pain. 3. After undertaking any other appropriate development deemed necessary, readjudicate the issues on appeal based on the additional evidence of record. If the determinations remain adverse to the Veteran, he and his representative must be provided with a supplemental statement of the case. An appropriate period of time must then be allowed for a response before the record is returned to the Board for further review. John J. Crowley Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Snoparsky 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.