Citation Nr: 21007897 Decision Date: 02/11/21 Archive Date: 02/11/21 DOCKET NO. 13-07 439 DATE: February 11, 2021 REMANDED Entitlement to service connection for bilateral hip pain (claimed as painful joints) is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1977 to November 1982. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a March 2011 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously before the Board in June 2017 and November 2019 when it was remanded for further development. In an August 2019 rating decision, the RO granted service connection for Lyme Disease with fatigue and migratory joint pain. However, as the RO explained in the decision, the grant for migratory joint pain excluded the hips and left shoulder (which was already service-connected on a direct basis). Thus, the claim for service connection for bilateral hip pain is the only part of the original claim that remains on appeal.   Entitlement to service connection for bilateral hip pain (claimed as painful joints) is remanded. Although the additional delay is regrettable, the Board finds an additional remand is required before a decision can be made regarding the Veteran’s claim. In April 2019, the Veteran underwent VA examinations to determine the nature and etiology of the Veteran’s bilateral hip pain. During the examination, the examiner diagnosed a left hip fracture and noted that the Veteran’s right hip was normal on examination. The examiner then opined that the Veteran’s right hip pain was not caused by his Lyme disease. In support of that opinion, the examiner noted that the Veteran did not complain of right hip pain related to Lyme Disease. The examiner also noted that the Veteran was diagnosed with Lyme Disease approximately 10 years before the examination and was given a course of antibiotics that treated the condition, noting that the Veteran was not currently taking any medications or receiving any treatment for his Lyme Disease. The examiner also referenced medical literature which stated that one of the most common symptoms of Lyme Disease is joint pain (primarily of the larger joints, including the hips) but that it often occurs several months after onset and that severe and permanent joint damage can occur if the condition remains untreated. Regarding the left hip pain, the examiner noted that the Veteran did not complain of pain in the left hip until a work injury. However, secondary service connection may be granted for a disability that is proximately caused by or aggravated by a service-connected disability. See 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 448 (1995). The April 2019 examiner did not address aggravation; therefore, the medical opinion is incomplete and therefore inadequate. In December 2020, the Veteran underwent additional VA examinations. The examiner noted a diagnosis of a left hip fracture with residual pain and indicated that there was insufficient objective evidence to render a diagnosis for the right hip. The examiner then opined that the Veteran’s painful joints were less likely than not related to his Lyme disease. The examiner noted that it is extremely rare that joint pains of Lyme disease last more than five years and that the Veteran’s negative testing for Lyme disease in 2011 further ruled out the likelihood Lyme disease caused the claimed joint pains. The examiner also indicated that the Veteran’s joint pain was not aggravated by his Lyme disease. In support of the opinion, the examiner explained that, given the timeframe, it is very unlikely (if not impossible) the joint pains were affected by his Lyme disease because Lyme disease joint symptoms occur shortly after infection and usually resolve within five years. However, medical literature referenced by the April 2019 VA examiner indicated that severe and permanent joint damage can occur if Lyme disease remains untreated and, in this case, the record reflects that the Veteran suffered the insect bite in the 1980s and was not diagnosed until about 20 years later as the disease was difficult to diagnose and required several labs and studies of the Veteran’s spinal fluids, as noted in a May 2007 VA treatment record. The examiner, however, did not address this contradictory information in the opinion. Thus, the Board finds remand for a new medical opinion necessary. In addition, as the examiner indicated there was insufficient evidence to render a diagnosis for the right hip, an opinion as to whether the Veteran has a right hip diagnosis should be obtained on remand. The matters are REMANDED for the following actions: 1. Obtain any updated VA treatment records for the period from November 2020 to the present. 2. After obtaining any additional records, schedule the Veteran for a VA examination by a clinician other than the December 2020 VA examiner. The Veteran’s claims file, including this remand, is to be made available to the examiner for review. Following examination of the Veteran and a review of the claims file, the examiner is asked to provide an opinion on the following: (a) Identify any current disabilities of the right hip. If it is determined that the Veteran does not have a diagnosable disability, then address whether any pain or other symptoms cause functional impairment, to include completing the “Functional Impact” section of the report. (b) With respect to any disability of the right hip (or symptoms causing functional impairment) and the Veteran’s left hip fracture with residual pain, address the following: (b)(i) Whether the condition (or symptoms causing functional impairment) is at least as likely as not (a 50 percent or greater probability) caused by his service-connected Lyme disease. (b)(ii) Whether the condition (or symptoms causing functional impairment) is at least as likely as not (a 50 percent or greater probability) aggravated (i.e., worsened beyond natural progression) by his service-connected Lyme disease. In providing the opinions requested in (b), the examiner should address the medical literature referenced in the April 2019 VA examiner’s opinion. A complete rationale must be provided. If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation. The clinician must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the clinician must indicate whether any opinion could not be   rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. Paul Sorisio Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Jiggetts 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.