Citation Nr: 21008149 Decision Date: 02/11/21 Archive Date: 02/11/21 DOCKET NO. 15-23 913 DATE: February 11, 2021 ORDER Service connection for right hip degenerative joint disease (DJD) and trochanteric bursitis is granted. Service connection for left knee DJD is granted. REMANDED An initial rating higher than 50 percent for posttraumatic stress disorder (PTSD) is remanded. An initial compensable rating for right knee enthesopathy is remanded. An initial compensable rating for bilateral hearing loss is remanded. Service connection for residuals of malaria is remanded. Service connection for ischemic heart disease is remanded. FINDINGS OF FACT 1. The Veteran’s right hip DJD and trochanteric bursitis are related to falling injuries in service. 2. The Veteran’s left knee DJD is related to falling injuries in service. CONCLUSIONS OF LAW 1. The criteria for service connection for right hip DJD and trochanteric bursitis have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for left knee DJD have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the U.S. Army from February 1968 to February 1970. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2014 rating decision. Service Connection Right hip DJD and trochanteric bursitis Left knee DJD The Board concludes that the Veteran has current right hip and left knee disabilities that are related to injuries sustained during service. 38 U.S.C. §§ 1110, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). A February 2013 private evaluation shows the Veteran has current diagnoses of right hip DJD and trochanteric bursitis, and left knee DJD. Service treatment records do not specifically document any relevant complaints or treatment related to the right hip or left knee. However, the Veteran received the Combat Infantryman’s Badge. As a combat veteran, under 38 U.S.C. § 1154(b), his assertions regarding diseases or injuries incurred in service shall be sufficient proof of such incurrence, notwithstanding the fact that there is no official record of any incurrence. In that regard, he reported injuring his right hip and left knee as a result of falls during service. These statements establish the relevant in-service injuries. Thus, the question becomes whether the current disability is related to service. On this question there are probative opinions in favor of and against the claim. The evidence against the claim includes VA examinations for the hip and knee from May 2015. Regarding the right hip, the examiner diagnosed a strain and stated that there was no diagnosis during service, no chronicity of care, and no other nexus established. Regarding the left knee, the examiner stated no diagnosis was present, the condition shown in service was acute only, and there was no chronicity of care or other nexus established. The evidence in favor of the claim includes the February 2013 private evaluation. That physician acknowledged the Veteran’s reported in-service injuries, stated that he had experienced intermittent progressive pain since that time, and that his diagnosed conditions were more likely than not related to the injuries in service. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran’s current right hip and left knee disabilities are related to service. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND An initial rating higher than 50 percent for PTSD In a December 2017 statement, the Veteran asserted that his PTSD had increased in severity. He was last examined by VA in December 2013. He also identified VA treatment records from 2017 that were relevant to his claim. Notably, the claims file includes small portions of VA treatment records from various points in the appeal period, and it is unclear whether there are additional outstanding records that may be relevant. Therefore, the Veteran should be provided an opportunity to report for a VA examination to ascertain the current severity of his PTSD, and any outstanding VA treatment records from the appeal period should be obtained. An initial compensable rating for right knee enthesopathy The outstanding VA treatment records above may be relevant to the Veteran’s claim for a higher rating for his right knee. In addition, he was last examined by VA for his right knee in May 2015. Therefore, the claim should be remanded for a new examination and consideration of any relevant VA treatment records. An initial compensable rating for bilateral hearing loss The outstanding VA treatment records above may be relevant to the Veteran’s claim for a higher rating for hearing loss. In addition, he was last examined by VA for his hearing loss in December 2013. Therefore, the claim should be remanded for a new examination and consideration of any relevant VA treatment records. Service connection for residuals of malaria. Service treatment records show the Veteran was admitted for treatment of malaria in January 1969. He was discharged several weeks later after becoming asymptomatic. A private medical evaluation in February 2013 diagnosed the Veteran with residuals of malaria, noting that he was subject to recurrent episodes of chills, fever and malaria symptoms which last about 10 days and require treatment and bed rest. However, a December 2013 VA examination stated that the Veteran had no symptoms consistent with active malaria, and that the condition was inactive as of 1969. The examiner stated that a malaria smear test was performed, and that the examination report would be amended when the results became available. However, a review of the evidence does not show that this test result was ever reported. In order to reconcile the conflicting evidence, VA should obtain the outstanding treatment records, and a new examination, including a malaria smear, should be conducted.   Service connection for ischemic heart disease Because the outstanding VA treatment records may be relevant to this claim, it must also be remanded. The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from January 2013 to the present. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected PTSD. The examiner should provide a full description of the disability and report all signs and symptoms associated with PTSD. The examiner must attempt to elicit information regarding the severity, frequency, and duration of symptoms. To the extent possible, the examiner should identify any symptoms and social and occupational impairment due to PTSD alone. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected right knee disability. The examiner should provide a full description of the disability and report all signs and symptoms associated with right knee enthesopathy. In so doing, the examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. If it is not possible to provide a specific measurement based on direct observation, the examiner should provide an estimate, if possible, of the additional impairment due to flare-ups based on the other evidence of record and the Veteran’s statements. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 4. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected bilateral hearing loss. The examiner should provide a full description of the disability and report all signs and symptoms associated with his hearing loss. 5. Schedule the Veteran for a VA examination for his claimed malaria. The examiner should obtain a complete history from the Veteran regarding any symptoms or residuals of malaria. The examiner should also perform a malaria smear, or any other appropriate objective test, to determine whether active malaria or residuals of malaria are present. JOHN Z. JONES Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Shamil Patel, Counsel 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.