Citation Nr: 21076071 Decision Date: 12/22/21 Archive Date: 12/22/21 DOCKET NO. 14-35 188A DATE: December 22, 2021 REMANDED The issue of service connection for a right hip disorder, to include strain and degenerative joint disease, to include as secondary to service-connected thoracolumbar spine degenerative disc disease is remanded. The issue of service connection for a left hip disorder, to include strain and degenerative joint disease, to include as secondary to service-connected thoracolumbar spine degenerative disc disease is remanded. The issue of service connection for a left breast cyst to include as secondary to service-connected right breast fibrocystic breast disease and/or breast microcalcification is remanded. The issue of service connection for residuals of breast reduction, to include as secondary to service-connected right breast fibrocystic breast disease and/or breast microcalcification is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Army from February 1988 to July 2012, to include service in Southwest Asia. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2013 rating decision of the Winston-Salem, North Carolina Regional Office (RO). In February 2018, the Veteran was afforded a videoconference hearing before the undersigned Veterans Law Judge (VLJ). During the hearing, the VLJ engaged in a colloquy with the Veteran toward substantiation of the claims. Bryant v. Shinseki, 23 Vet. App. 488, 496-97 (2010). A hearing transcript is in the record. In November 2020, the Board remanded the claims of service connection for a right and left hip disorder to the RO for additional action. The RO did not substantially comply with the Board's remand directives. Stegall v. West, 11 Vet. App. 268 (1998). Right hip disorder, left hip disorder, left breast cyst, and breast reduction The matters are remanded for the following actions: 1. BACKGROUND FOR THE RO ADJUDICATOR In November 2020, the Board remanded the claims of service connection for a right and left hip disorder for an adequate VA medical opinion as to direct and secondary service connection. The April 2021 and June 2021 VA addendum opinions as to both claims were inadequate for three reasons: (1) as to whether the Veteran has a current right and left hip degenerative joint disease, the examiner did not consider the April 2019 VA right hip radiograph revealing "early degenerative change affecting the right hip" and the January 2020 VA left hip radiograph revealing "mild left hip degenerative changes," (2) the examiner indicated that there were "no pertinent service treatment records" concerning the Veteran's hips; however, service treatment records do show notations of bilateral hip complaints, and (3) as to the negative etiology opinion for secondary service connection, the examiner did not address causation and aggravation separately with rationale specific to those findings under Atencio v. O'Rourke, 30 Vet. App. 74 (2018). In November 2020, the Board denied the claims of service connection for a left breast cyst and residuals of breast reduction surgery. The Veteran appealed the Board decision to the U.S. Court of Appeals for Veterans' Claims (Court). In a July 2021 Joint Motion for Partial Remand (JMPR), the Court vacated the Board decision and remanded the Veteran's appeal to the Board. The Court found that the Board, in denying service connection for a left breast cyst and breast reduction, relied on the November 2019 VA examiner's finding that there were no findings, signs, or symptoms to support a diagnosis of a left breast cyst or breast reduction. However, the Court indicated that the Board did not consider the November 2019 VA examiner's finding that the Veteran has residuals of breast reduction surgery and did not consider this information as a claim of service connection encompassing the additional diagnosis or symptoms under Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Court specifically noted the Veteran's diagnosis of "benign fibrocystic breast disease s/p left breast lumpectomy for suspicious microcalcifications" and the Veteran's report of "microcalcifications in two locations." The Veteran's right breast fibrocystic breast disease and breast microcalcification are service connected. The Board will remand the claims to a VA gynecologist for addendum opinions. THE REMAND DIRECTIVES FOLLOW. 2. Return the file to the VA examiner who provided the April 2021 and June 2021 medical opinions as to the Veteran's right and left hip disorder for a file review and an addendum opinion. If the examiner is not available, have the file reviewed by a similarly qualified examiner. Another examination is not required; however, if the VA examiner indicates that he or she cannot respond to the Board's questions without examination of the Veteran, another examination should be afforded to the Veteran. All relevant medical and non-medical records must be made available to the examiner for review of pertinent documents. The examination report should specifically state that such a review was conducted. The examiner must provide the following opinions. Does the Veteran have a diagnosis of right hip degenerative joint disease (DJD) or any other degenerative disorder? Does the Veteran have a diagnosis of left hip DJD or any other degenerative disorder? If the Veteran has right hip DJD or any other degenerative disorder, are the Veteran's in-service notations of right hip pain manifestations of her right hip DJD or other degenerative disorder? If the Veteran has left hip DJD or any other degenerative disorder, are the Veteran's in-service notations of left hip pain manifestations of her left hip DJD or other degenerative disorder? Was the Veteran's right hip disorder, to include strain and any other diagnosed degenerative disorders caused by service? Was the Veteran's left hip disorder, to include strain and any other diagnosed degenerative disorders caused by service? Was the Veteran's right hip disorder, to include strain and any other diagnosed degenerative disorders caused by service-connected thoracolumbar spine degenerative disc disease? Was the Veteran's left hip disorder, to include strain and any other diagnosed degenerative disorders caused by service-connected thoracolumbar spine degenerative disc disease? Was the Veteran's right hip disorder, to include strain and any other diagnosed degenerative disorders aggravated by service-connected thoracolumbar spine degenerative disc disease? Was the Veteran's left hip disorder, to include strain and any other diagnosed degenerative disorders aggravated by service-connected thoracolumbar spine degenerative disc disease? Although the examiner must review the VBMS file, his or her attention is drawn to the following: A July 2009 service treatment record titled "physical therapy treatment flow sheet" reflects a diagnosis of chronic low back pain with hip pain. It was noted that the Veteran's symptoms had onset in 2004. In service treatment records dated July 2009 to November 2009, the section titled "problem list" reflects "localized hip joint pain." A November 2009 service treatment record reflects the Veteran's report of right hip pain. A physical examination revealed normal findings and the Veteran was assessed with right hip pain. In service treatment records dated November 2009 to March 2010, the section titled "problem list" reflects "localized hip joint pain." In an April 2010 service treatment record, the service medical examiner noted no bilateral hip weakness and a normal gait. In service treatment records dated June 2010 to May 2012, the section titled "problem list" reflects "localized hip joint pain." In her June 2012 pre-separation medical history report, the Veteran answered "no" to the question of whether she then had, or once had swollen or painful joints, and any other bone, joint, or other deformity. In her June 2012 service medical assessment report, the Veteran did not report any health concerns pertaining to her hips. The September 2012 VA general medical examination noted hip joint symptoms. A September 2012 VA bilateral hip radiograph revealed well approximated sacroiliac joints and pubic symphysis, femoral heads articulate normally with acetabula, no acute fracture or subluxation, and no significant appearing arthropathic changes. In an April 2014 VA treatment record, the VA treating physician noted bilateral hip decreased range of motion, no tenderness to palpation, and normal gait. In an August 2014 VA treatment record, the VA treating physician noted bilateral hip decreased range of motion and no tenderness to palpation. In the February 2018 Board hearing, the Veteran testified to having a right hip degenerative condition and that her left hip disorder was secondary to service-connected thoracolumbar spine degenerative disc disease. A November 2019 VA bilateral hip radiograph revealed "visualized skeletal structures appear to be unremarkable and the joint spaces preserved, no fractures, dislocations, or other significant abnormality, negative bilateral hips, no evidence of degenerative joint disease." The November 2019 VA examiner diagnosed the Veteran with a bilateral hip strain. A January 2020 VA left hip radiograph revealed no acute osseous abnormality, mild degenerative changes, and shallow lateral acetabulum with mild dysplasia. A February 2020 VA treatment record reflects the Veteran's report of left hip pain. The April 2021 VA examiner diagnosed the Veteran with a bilateral hip strain. 3. Send the file to a VA gynecologist for a file review and addendum opinions. All relevant medical and non-medical records must be available to the VA gynecologist for review of pertinent documents. The examination report should specifically state that such a review was conducted. Left breast cyst: the VA gynecologist must provide the following opinions: Was the Veteran's left breast cyst caused by service? Was the Veteran's left breast cyst caused by service-connected right breast fibrocystic breast disease and/or breast microcalcification? Was the Veteran's left breast cyst aggravated by service-connected right breast fibrocystic breast disease and/or breast microcalcification? Although the VA gynecologist must review the VBMS file, his or her attention is drawn to the following: In a January 2009 service treatment record, a section titled "problem list" noted a breast palpation mass. In a March 2010 service treatment record, a review of systems revealed no breast symptoms. In an April 2010 service treatment record, a review of systems revealed no breast lump and no breast pain. An August 2010 service treatment record reflects the Veteran's report of hypomastia and her interest in breast augmentation. A bilateral breast examination revealed pendulous, ptosis, atrophy, and no other abnormalities. In a September 2010 service treatment record, a review of systems revealed no breast lump and no breast pain. A December 2010 service mammogram revealed suspicious clusters of microcalcifications in the left inner lower breast. A December 2010 service breast ultrasound revealed two separate clusters of suspicious microcalcifications in the left breast, a cyst in the left retroareolar tissues with a 1-2 millimeter hypoechoic density immediately adjacent to the cyst, and probable asymmetric tissue in the right upper breast. In a January 2011 service treatment record, the Veteran was assessed with breast palpation mass. In February 2011, the Veteran underwent a biopsy to remove left breast calcifications. The service biopsy revealed breast tissue with fibrocystic changes including metaplasia, cyst formation, sclerosing adenosis, and duct ectasia. The Veteran was diagnosed with left breast lumpectomy. In her June 2012 pre-separation medical history report, the Veteran answered "yes" to the question of whether she then had, or once had a gynecological disorder. In her June 2012 service medical assessment report, the Veteran did not report any health concerns concerning her breasts. The September 2012 VA examiner diagnosed the Veteran with a resolved left breast cyst and right breast fibrocystic breast disease. A July 2013 VA mammogram revealed normal findings. A July 2015 VA abdomen radiograph revealed left granular breast tissue not clearly identified possibly related to a high riding left breast. The possibility of post-surgical changes could not be excluded. In the February 2018 Board hearing, the Veteran testified to having breast reduction in February 2011. The November 2019 VA examiner diagnosed the Veteran with benign fibrocystic breast disease status-post left breast lumpectomy for suspicious microcalcifications with then-current symptoms of breast tenderness, pain, and small left breast. The November 2019 VA examiner indicated there was no evidence of a left breast cyst. Breast reduction surgery: the VA gynecologist must provide the following opinions: Was the Veteran's residuals of breast reduction caused by service? Was the Veteran's residuals of breast reduction caused by service-connected right breast fibrocystic breast disease and/or breast microcalcification? Was the Veteran's residuals of breast reduction aggravated by service-connected right breast fibrocystic breast disease and/or breast microcalcification? Although the VA gynecologist must review the VBMS file, his or her attention is drawn to the following: In a January 2009 service treatment record, a section titled "problem list" noted a breast palpation mass. In a March 2010 service treatment record, a review of systems revealed no breast symptoms. In an April 2010 service treatment record, a review of systems revealed no breast lump and no breast pain. An August 2010 service treatment record reflects the Veteran's report of hypomastia and her interest in breast augmentation. A bilateral breast examination revealed pendulous, ptosis, atrophy, and no other abnormalities. In a September 2010 service treatment record, a review of systems revealed no breast lump and no breast pain. A December 2010 service mammogram revealed suspicious clusters of microcalcifications in the left inner lower breast. A December 2010 service breast ultrasound revealed two separate clusters of suspicious microcalcifications in the left breast, a cyst in the left retroareolar tissues with a 1-2 millimeter hypoechoic density immediately adjacent to the cyst, and probable asymmetric tissue in right upper breast. In a January 2011 service treatment record, the Veteran was assessed with breast palpation mass. In February 2011, the Veteran underwent a biopsy to remove left breast calcifications. The service biopsy revealed breast tissue with fibrocystic changes including metaplasia, cyst formation, sclerosing adenosis, and duct ectasia. The Veteran was diagnosed with left breast lumpectomy. In her June 2012 pre-separation medical history report, the Veteran answered "yes" to the question of whether she then had, or once had a gynecological disorder. In her June 2012 service medical assessment report, the Veteran did not report any health concerns concerning her breasts. The September 2012 VA examiner diagnosed the Veteran with a resolved left breast cyst and right breast fibrocystic breast disease. A July 2013 VA mammogram revealed normal findings. A July 2015 VA abdomen radiograph revealed left granular breast tissue not clearly identified possibly related to a high riding left breast. The possibility of post-surgical changes could not be excluded. In the February 2018 Board hearing, the Veteran testified to having breast reduction in February 2011. The November 2019 VA examiner diagnosed the Veteran with benign fibrocystic breast disease status-post left breast lumpectomy for suspicious microcalcifications with then-current symptoms of breast tenderness, pain, and small left breast. 4. Readjudicate the issues on appeal. If the benefits sought on appeal remain denied, the Veteran should be provided a supplemental statement of the case (SSOC). An appropriate period should be allowed for response before the case is returned to the Board. Vito A. Clementi Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Cohen, Counsel The Board's action is binding only in this case. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.