Citation Nr: 21011762 Decision Date: 03/02/21 Archive Date: 03/02/21 DOCKET NO. 17-29 107 DATE: March 2, 2021 REMANDED Entitlement to service connection for a left hip disability (claimed as left flank) is remanded. Entitlement to service connection for a right hip disability (claimed as right flank) is remanded. Entitlement to service connection for a low back disability is remanded. Entitlement to service connection for vertigo/dizziness is remanded. Entitlement to service connection for motion sickness is remanded. Entitlement to service connection for headaches is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from November 1985 to September 1994. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In July 2020, the Veteran testified at a virtual hearing held before the undersigned Veterans Law Judge. A copy of the transcript of the hearing is of record. Further development is found needed prior to adjudication of these claims, so as to meet VA’s duty to assist the Veteran in substantiating her claims. As an initial matter, it does not appear that the Veteran’s treatment records from Fort Belvoir from 1995 to 1999 have been obtained and associated with the claims file. At the Board hearing, the Veteran’s representative noted that such treatment records would be for her as a dependent. On remand, all necessary action should be taken to obtain these records, unless and until it is determined that further efforts would be futile. The Veteran has not yet been provided with VA examination and medical opinion with regard to the claims here on appeal. Considering the evidence of record, the Board will not proceed with final adjudication of these claims until such examinations and opinions addressing the etiology of the Veteran’s claimed disorders are obtained. See McLendon v. Nicholson, 20 Vet. App. 79. 1. Entitlement to service connection for a left hip disability (claimed as left flank) is remanded. 2. Entitlement to service connection for a right hip disability (claimed as right flank) is remanded. 3. Entitlement to service connection for a low back disability is remanded. The Veteran asserts that she suffered from groin pain and pain in the buttock/hip area and back pain since service, and for years before it became bad enough that she sought medical care. She attributes this to significant heavy lifting during active service, and also to an incident in December 1987 where she was violently thrown from the back of a bucking horse. The Veteran’s treatment records demonstrate current lumbar and bilateral hip disabilities, and her service treatment records document low back strain from heavy lifting in March 1987, complaints of left and right side sharp flank pain in December 1992, back spasms on her June 1994 separation examination, and emergency treatment following being thrown from a horse (albeit without mention of back or hip symptoms) in December 1987. In finding that remand is needed for an examination and medical opinion pertaining to the Veteran’s bilateral hips claim, the Board recognizes that a September 2020 letter from the Chief of Arthroplasty, USAFA is of record stating an opinion that it is likely that the Veteran’s fall from the horse during service “could have propagated the progression of her hip osteoarthritis that resulted in early hip replacement.” However, the opinion letter does not reflect review of the Veteran’s treatment records over time, which includes a February 2010 orthopedic evaluation noting a long history of problems stemming from a lower back injury originally in 2004 and an incident in 2008 where she fell when a dresser fell onto her right thigh, noting treatment for right hip pain since the 2008 accident. As it is unclear from the letter whether the physician reviewed or was aware of this evidence, his opinion, alone, is found to provide an inadequate basis for an award of service connection. On remand, the Veteran should be provided with VA examination and medical opinion concerning the nature and etiology of her claimed back and bilateral hip disabilities. 4. Entitlement to service connection for vertigo/dizziness is remanded. 5. Entitlement to service connection for motion sickness is remanded. 6. Entitlement to service connection for headaches is remanded. The Veteran asserts that she suffers from vertigo/dizziness, motion sickness, and headaches relating to her active naval service. She contends that she has experienced these problems during and since service, and that they are related to her exposure to altitude and pressure changes while flying in helicopters and fixed wing aircraft and/or to a head injury she believes she sustained when being thrown from a horse in December 1987. The Veteran’s service treatment records include a number of instances where the Veteran sought treatment for symptoms including mild nausea, headache, light-headedness, fatigue, and dizziness (see STRs from June 1986, March 1990, and March 1992). At November 1992 emergency treatment following being thrown from a horse in December 1987, it was noted that the Veteran had a contusion about her left periorbital area. The Veteran was additionally seen in November 1992 for complaints of a 15-minute episode of flushing and dizziness after quickly rising from her chair, which was assessed as a brief vasovagal episode, and in March 1993 for evaluation of motion sickness. The March 1993 STR indicates that a neurologist was consulted, who recommended use of a scopolamine patch prior to flying. Treatment records from during the relevant appeal period indicate that the Veteran has reported headaches, dizziness, vertigo, motion sickness, and difficulty thinking to her healthcare providers. Finally, an August 2020 neurology note indicates that the neurologist discussed that her work-up including the MRI were unremarkable with no structural etiology of her symptoms identified, but that she could not completely exclude that the Veteran’s dizziness was from a prior head injury or airplane exposure. The Board additionally notes that an October 2015 treatment record indicates that the Veteran had been getting headaches over the past week, approximately one week after a motor vehicle accident. She reported that she was rear ended while at a stop without airbags, and had pain in the back of her head right away and throughout the day of the accident in September 2015, and then the back of her neck started hurting. On remand, the Veteran should be provided with a VA examination and medical opinion concerning the nature and etiology of her claimed vertigo/dizziness, motion sickness, and headache disabilities. The matters are REMANDED for the following action: 1. Obtain the Veteran’s records for her treatment at Fort Belvoir between 1995 and 1999 (while she was a dependent). Document all requests for information as well as all responses in the claims file. 2. After completing the development requested in directive #1, schedule the Veteran for a VA examination to assess the nature and etiology of her claimed low back disability. The examiner must review the claims file and consider the lay and medical evidence of record, to include the medical literature submitted on the Veteran’s behalf in February 2021. For any low back disability present at any time during the relevant appeal period (March 2015 to present), is it at least as likely as not (50 percent or greater probability) related to service, to include her documented in-service muscular back pain/spasms after heavy lifting and being thrown from a horse? Provide a rationale to support the opinion(s). In providing the requested opinion, consider the Veteran’s description of her in-service injury and symptoms as well as her post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran’s reported injury and symptoms in service and thereafter represented the onset of her current disability, this should be noted. 3. After completing the development requested in directive #1, schedule the Veteran for a VA examination to assess the nature and etiology of her claimed left and right hip disability. The examiner must review the claims file, and consider the lay and medical evidence of record, including the medical literature evidence pertaining to horse-riding injuries and hip disabilities, and private medical opinion and medical literature submitted in February 2021. For any hip disability present at any time during the relevant appeal period (March 2015 to present), is it at least as likely as not (50 percent or greater probability) related to service, to include the Veteran’s in-service right and left flank pain and/or being thrown from a horse? Provide a rationale to support the opinion(s). In providing the requested opinion, consider the Veteran’s description of her in-service injury and symptoms as well as her post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran’s reported injury and symptoms in service and thereafter represented the onset of her current disability, this should be noted. 4. After completing the development requested in directive #1, schedule the Veteran for an examination with an appropriate medical professional to assess the nature and etiology of her claimed vertigo/dizziness, motion sickness, and headaches. The examiner must review the claims file, and consider all lay and medical evidence of record, to include medical literature submitted on the Veteran’s behalf in February 2021. The examiner is asked to address the following: a. The examiner should identify a diagnosis for any disability manifesting in the Veteran’s vertigo/dizziness, motion sickness, and/or headaches, specifically confirming or ruling out traumatic brain injury. If a diagnosis cannot be provided but the Veteran’s condition manifests in symptoms that cause functional impairment, then the examiner should consider them a “disability” for the purpose of providing the requested opinion, below. b. For any disability causing vertigo/dizziness, motion sickness, and/or headaches at any point during the relevant appeal period (March 2015 to present) is the disability at least as likely as not related to service, including the Veteran’s exposure to altitude and pressure changes while flying in helicopters and fixed wing aircraft and/or to a head injury she believes she sustained when she was thrown from a horse in December 1987. Provide a rationale to support the opinions. Responding to the above, consider the Veteran’s description of her in-service injury and symptoms as well as her post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran’s reported injury and symptoms in service and thereafter represented the onset of her current disability, this should be noted. 5. After completing the above, and conducting any further development deemed necessary in light of the expanded record, readjudicate the claims on appeal. If any benefit sought is not granted in full/to the Veteran’s satisfaction, issue the Veteran and her representative a supplemental statement of the case and allow an opportunity to respond before returning the appeal to the Board, if in order. MICHAEL MARTIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Solomon, 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.