Citation Nr: 21015426 Decision Date: 03/17/21 Archive Date: 03/17/21 DOCKET NO. 14-44 508 DATE: March 17, 2021 REMANDED Entitlement to service connection for left hip disability (to include avascular necrosis (AVN)), to include as secondary to service-connected disabilities, is remanded. REASONS FOR REMAND The Veteran served on active duty from December 1985 to September 1989. This matter initially came before the Board of Veterans’ Appeals (Board) from an August 2013 rating decision. In an October 2018 Board decision, the Veteran’s application to reopen the claim of service connection for left hip disability was granted, and the underlying claim for service connection was remanded for further evidentiary development. However, although the Board sincerely regrets the additional delay, another remand is necessary to afford the Veteran due process of law and to ensure that there is a complete record upon which to decide his appeal. First, in an October 2020 representative Brief, the Veteran’s representative argued that there was not substantial compliance with the Board’s prior remand directives; specifically, that a VA examiner’s opinion was not adequate. Therefore, the Veteran, through his representative, requested the Board to again remand the claim for an adequate medical opinion. The Board agrees with the Veteran and his representative and finds part of the opinion to be conclusory and not probative in value. Specifically, the Veteran was afforded a VA hip examination in October 2019 and the examiner opined that there was no evidence that the Veteran’s service-connected disabilities caused or aggravated the claimed left hip disability beyond its natural progression, as there was no evidence of a fall, trauma or complication with the service-connected disabilities causing a left hip disability in the records. Therefore, there was no evidence of causation or aggravation in the records. The Board finds this to be inadequate as it is merely conclusory without considering the Veteran’s specific service-connected disabilities and the symptoms of those disabilities, but rather relies on there being no specific “event” such as a fall or trauma. Further, the Veteran has consistently contended that his left hip disability, diagnosed as AVN, was caused by the numerous steroid injections which he has received for his service-connected disabilities. In the September 2018 Brief, the Veteran’s representative contended that any or all of the Veteran’s service-connected disabilities may have aggravated his left hip disability beyond its natural progression. The representative cited medical literature which described a case of rapid-onset AVN occurring five weeks after a single injection of corticosteroid into the hip joint. See Kassam, A M. “Accelerated Avascular Necrosis after Single Intra-Articular Injection of Corticosteroid into the Hip Joint.” Additionally, following the 2018 Board remand, in a June 2020 statement, the Veteran contended that he was told by his private doctors that the AVN was possibly from the years of steroid injections for his back, right hip, ankle, and bilateral knees – all of which are service-connected. He also stated articles he submitted indicate that several injections of cortisone steroids, regardless of the area the injection is given, can develop AVN and affect more than one joint at a time. Finally, the 2018 Board remand directives requested the agency of original jurisdiction (AOJ) to make two requests for the Veteran’s private medical records before completing the rest of the directives, which they did not do. The Board notes that the August 2013 VA examiner and the 2019 VA examiner both opined that AVN can be related to systemic steroid usage; however, there is no evidence that the Veteran received systemic (oral or intravenous) steroid treatments, but rather he received several injections to a specific joint area, which is a localized steroid injection. However, the Veteran specifically stated in his 2013 notice of disagreement that he had been seen by three different private doctors who treated his musculoskeletal conditions, to include the steroid injections. As such, those records are possibly relevant to this appeal, and on remand, the AOJ must attempt to retrieve them. Additionally, the Board notes that VA medical records appear to not be in the file, nor were they listed in the rating decision or the 2014 statement of the case or the June 2020 supplemental statement of the case. There are records from the VAMC in Atlanta from January 2003 through March 2010, and records from November 2015 through June 2016. On remand, all VA medical records must be obtained and associated with the claims file. The matter is REMANDED for the following action: 1. Obtain the Veteran’s outstanding VA treatment records from the Atlanta VA Health Care System for the periods from March 2010 through November 2015, and since June 2016 to present; and all such relevant records from any other sufficiently identified VA facility. 2. Send to the Veteran a letter and ask him to complete a VA Form 21-4142 requesting that he provide sufficient information concerning, and, if necessary, authorization to enable VA to obtain any additional records pertaining to treatment for left hip disability that are not currently of record; specifically to include treatment records from Dr. P. Richin and Dr. D. Dounte and Dr. C. Jarrett. Make two requests for any authorized records from any identified physician or medical facility and if any private records identified by the Veteran are not obtained, notify him and his representative of such and give them an opportunity to obtain the records and submit them. 3. After, and only after, all efforts have been exhausted to obtain and associate with the claims file any additional treatment records, obtain an addendum opinion from an appropriate clinician to address whether the Veteran’s claimed left hip disability is caused or aggravated by service-connected disability. The claims file, including a copy of this remand, must be provided to the clinician in conjunction with the requested opinions. Then, the clinician must opine as to the following, with full supporting rationales: (a.) Is it at least as likely as not (50 percent or better probability) that any left hip disability experienced by the Veteran since approximately January 2013 was caused by his service-connected disabilities (to include any medications used to treat these disabilities, such as steroid injections), to include his severe right knee instability, severe left knee subluxation with moderate instability, back disability, bilateral pes planus with hallux valgus, degenerative joint disease of the right knee, degenerative joint disease of the left knee, right hip disability, and right ankle disability? Please address the argument that the Veteran’s claimed left hip disability is related to and causally due to steroid treatments for his service-connected disabilities over the years, to include in his right knee, left knee, back, right hip, and right ankle. (b.) Is it at least as likely as not (50 percent or better probability) that any left hip disability experienced by the Veteran since approximately January 2013 was aggravated by his service-connected disabilities, to include his severe right knee instability, severe left knee subluxation with moderate instability, back disability, bilateral pes planus with hallux valgus, degenerative joint disease of the right knee, degenerative joint disease of the left knee, right hip disability, and right ankle disability? A complete explanation should be provided for all opinions on causation AND aggravation. The clinician is advised that aggravation of a condition for legal purposes is defined as any incremental increase in disability, meaning any additional impairment of earning capacity above the degree of disability existing before the increase, in a nonservice-connected disability resulting from a service-connected disability, regardless of its permanence. The clinician is asked to consider: • 1999 private medical records indicating that the Veteran had a leg length discrepancy with the right shorter than the left and that he had pronation when he walked; • the 2001 ACL tear with an ACL reconstruction and meniscal procedure of his left knee; • February 2003 - reported pain with walking, standing, running and sitting, and that he felt like one leg was longer than the other; • the April 2003 VA medical records which showed that the Veteran was prescribed two sprays of corticosteroid nasal inhalations daily; • February 2007, his private doctor aspired • June 2007 left knee arthroscopy; • June 2008 private records showing that the Veteran had numbness and pain in the right leg and hip with limited motion; • The private medical records received August 2008 showing: August 3, 2005 (anti-inflammatory agent as needed, possible injection); August 17, 2005 (aspirated...[and] placed some cortisone in the knee); July 7, 2006 (re-inject the right knee today); October 9, 2006 (related to knee: we have gone ahead and done a cortisone injection today); February 9, 2007 (aspired joint type fluid from the knee and put some cortisone in); June 1, 2007 (we did a cortisone injection today); September 5, 2007 (injection to shoulder; relief only lasted about a week; recheck in 2 months. Possible re injection); November 1, 2007 (shoulder responds nicely to cortisone injections; they don’t seem to last as long as we would like; another injection today); • Private medical records received September 2008 showing March 26, 2008 (Today we injected both knees with Marcaine, lidocaine and Depo-Medrol to provide him with some sort of relief.) Depo-Medrol is a corticosteroid. Addendum dated May 20, 2008 (numerous operations on both knees...Right now we are treating him symptomatically with intra-articular corticosteroid injections and hyaluronic acid injections.); • April 2009 reported low back pain, knee and foot pain, right knee injections, surgery of left knee June 2007 and reported he had hip pain; • June 2009 VA record noting he had left knee pain with steroid injections, with a series of Hyalgan injections five times bilaterally 2 series, for 8 months for the left knee; • The July 2010 letter that the Veteran had been treated for many years with steroids for his back as well as NSAIDS; • In October 2010 he had epidural injections for his back condition; • Podiatry records from July 2011 with a letter from the podiatrist referencing attempts to address the Veteran’s pain in several ways, including “shots of anti-inflammatory medication”; • the March 2013 private physician letter that the Veteran’s AVN may be attributed to multiple cortisone injections in the hip plus degenerative joint disease; • the June 2013 VA medical examiner opined that the Veteran’s left hip disability was at least as likely as not related to cortisone injections in the knee joints and low back; • the August 2013 examiner noted that AVN can be caused by systemic steroids, but not localized steroid injections, and noted the Veteran only received localized steroid injections; • the September 2018 Brief which cited medical literature which described a case of rapid-onset AVN occurring five weeks after a single injection of corticosteroid into the hip joint; • the 2018 Brief where the representative argued that the Veteran’s ability to sit, stand and walk necessitates the coordinated functioning of both lower extremities and that any or all of the service-connected disabilities (or the treatment for them) may contribute to the left hip disability; • the medical literature submitted by the Veteran in June 2020, to include statistics on corticosteroid use; • the article on epidemiology of osteonecrosis (ON) which noted that the most common site of ON was the hip, representing 75.9% of the cases; • the Veteran’s June 2020 statement that he was told that “possibly from the years of steroid injections I had been getting over the years for my back, right hip, ankle, both knees...all that are service-connected” and stated articles he submitted indicate that several injections of cortisone steroids regardless of the area the injection is given can develop AVN and affect more than one joint at a time; • medically reviewed article by Dr. W. Morrison, which noted that causes of AVN include taking high doses of corticosteroids for a long time, such as prednisone or cortisone, because they can increase fatty substances (lipids) in the blood, which can block arteries; and • the 2019 article which cited a study that hip and knee steroid injections may cause accelerated arthritis and joint destruction, as well as osteonecrosis. A rationale must be provided for any opinions proffered. Brian J. Elwood Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G.Hoy, Associate 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.