Citation Nr: 21011901 Decision Date: 03/03/21 Archive Date: 03/03/21 DOCKET NO. 17-47 243 DATE: March 3, 2021 REMANDED Entitlement to service connection for left hip disorder is remanded. Entitlement to back disorder, to include as secondary to left hip disorder, is remanded. REASONS FOR REMAND The Veteran had active duty in the United States Army from February 1976 to February 1979 including qualification as a paratrooper. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2012 rating decision by the Department of Veterans Affairs (VA) RO in Indianapolis, Indiana. In February 2020, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of that proceeding has been associated with the Veteran’s claims file. Regrettably, another remand is necessary in this case to ensure that due process is followed and that there is a complete record upon which to decide the Veteran’s claim so that he is afforded every possible consideration. 38 U.S.C. § 5103; 38 C.F.R. § 3.159 Discussion The Veteran contends that left hip disorder and back disorder were incurred in, aggravated by, or otherwise attributable to, active duty service. In an October 2012 notice of disagreement and in testimony during the Board hearing, the Veteran reported that he had a weak hip as a child and was told after service by physicians that he had Perthes disease in that hip. He testified that he was required to perform extensive running and forced road marches as well as parachute jumps. He testified that he was often lagging the rest of his unit during marches and had an abnormal gait while in service. Service treatment records including a January 1976 enlistment physical examination, a January 1979 discharge examination, and all outpatient treatment records are silent for any symptoms, diagnoses, or treatment for left hip or back injuries or abnormalities including a leg length difference. At enlistment, the Veteran was found qualified for paratrooper training. There is a 265-page file of magnetic resonance imaging (MRI) or computed tomography (CT) images, without any associated clinical interpretation. Although posted in the file as service records, there are no annotations as to the date or source of these images. As there is no clinical notation that imaging was ordered at any time in service, the Board finds that these images are not service records but likely studies referenced in private post-service treatment records. In a March 2010 VA joint examination report, a clinician opined that Veteran’s joint disabilities (hip and back) were not caused by or a result of service. As a rationale for this negative nexus opinion, the clinician noted that “previous disease is an injury sustained during adolescence or rapid growth which was well healed” upon induction. See March 17, 2010 VA Examination, p. 7. In August 2010, a private physical therapist, Ms. S., noted that the Veteran presented with a left leg one inch shorter than the right and that the Veteran reported a past history of Perthes disease of the left hip. The therapist noted that this was a childhood disease causing deformity and permanent structural changes of the femoral head that many times leads to a leg length discrepancy. The resulting asymmetrical gait and posture causes muscle imbalance and arthritic changes in the hip and back if uncorrected into adulthood. The therapist noted the Veteran’s report of service in the infantry and that the high level of physical activity and stress would have aggravated the back and hip joint. Medical Treatment Record-Non-Government Facility, p. 11 of 12, October 29, 2010. Upon receipt of the Veteran’s private medical records from FPN, in a September 12, 2017 progress note, Dr. M., a provider at FPN wrote: [The Veteran] could consider injections, right now I do recommend surgery [… The Veteran] certainly has hip arthritis, bursitis, and Perthes, some of which is congenital but some of which certainly could have been exacerbated by his service as a paratrooper. See May 26, 2020 Medical Treatment Record—Non-Government Facility, p. 8. A medical opinion is adequate when it is based upon consideration of the veteran’s prior medical history and examinations and describes the disability in sufficient detail so that the Board’s “‘evaluation of the claimed disability will be a fully informed one.’” Ardison v. Brown, 6 Vet. App. 405, 407 (1994). The discrepant medical findings of Dr. M., Ms. S (physical therapist), and the March 2010 VA clinician create a situation wherein the Board does not have an adequate medical opinion upon which it can render a fully informed decision. Therefore, additional evidentiary development is in order. The matters are REMANDED for the following actions: 1. Contact the Veteran and his representative to ascertain whether there are any outstanding private treatment records for left hip disorder and/or back disorder. If the Veteran and his representative identify additional records, prepare appropriate release forms, obtain the records, and associate then with the claims file. 2. Ascertain whether there are any outstanding VA treatment records. If identified, obtain the records and associate them with the electronic claims file. 3. Arrange for VA hip examination and VA spine (either cervical or thoracolumbar as appropriate) examination with an appropriate clinician. The Board asks that the clinician review the claims file. Upon completion of the above, the clinician is asked to respond to the following inquiries: a. Whether it is at least as likely as not (50 percent or more) that the Veteran’s left hip disorder was incurred in, aggravated by, or otherwise attributable to, any incidence of service? The clinician is asked to reconcile Dr. M.’s opinion, Ms. S (therapist) opinion, and the March 2010 VA clinician’s opinion, conducting any and all testing deemed necessary. Whether it is at least as likely as not (50 percent or more) that the Veteran’s back disorder was incurred in, aggravated by, or otherwise attributable to, any incidence of service? AND IF SO b. Whether it is at least as likely as not that the Veteran’s back disorder was proximately caused by, or aggravated beyond its natural progression by, the left hip disorder. The examination reports should specifically state that a review of the record was conducted. The clinician should provide a complete rationale for all opinions provided. If an opinion cannot be provided without resorting to mere speculation, the clinician should identify all medical and lay evidence considered in this conclusion, fully explain why this is the case and identify what additional evidence (if any) would allow for a more definitive opinion. The Board notes that the Veteran is competent to report discernable symptomatology, to include continuity of such. J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. J. Komins, 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.