Citation Nr: 21020690 Decision Date: 04/07/21 Archive Date: 04/07/21 DOCKET NO. 17-55 303 DATE: April 7, 2021 ORDER Service connection for bilateral shoulder disability is granted. Service connection for right hip disability is granted. REMANDED Entitlement to service connection for left ankle disability is remanded. FINDINGS OF FACT 1. The evidence as to whether the Veteran’s currently diagnosed bilateral shoulder disability was caused by an in-service event, injury, or disease is at least in relative equipoise. 2. The evidence as to whether the Veteran’s currently diagnosed right hip disability was caused by an in-service event, injury, or disease is at least in relative equipoise. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral shoulder disability have been met. 38 U.S.C. §§ 1101, 1110, 1111, 1131, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. 2. The criteria for service connection for right hip disability have been met. 38 U.S.C. §§ 1101, 1110, 1111, 1131, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Army from August 1982 to May 1987. He also had reserve service. These matters come before the Board of Veterans’ Appeals on appeal from July 2015 and March 2016 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran was denied service connection for bilateral shoulder disability and right hip disability in July 2015. He filed a fully developed claim in July 2015 and these claims were again denied in a December 2015 rating decision. He did not file a notice of disagreement within one year of the July 2015 and December 2015 rating decisions. However, VA was in receipt of new and material medical and lay evidence, within one year of the rating decisions, which addressed the claimed disabilities—specifically, the Veteran was afforded VA examinations in connection with these claims in December 2015. Therefore, any subsequent decisions must relate back to his original claim. The July 2015 rating decision did not become final and is one of the decisions on appeal. The Veteran first filed for service connection for left ankle disability in December 2015. This claim was denied in a March 2016 rating decision and is the other decision that is on appeal. The Veteran testified before the undersigned Veterans Law Judge in an April 2021 virtual hearing. Service Connection Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Hickson v. West, 12 Vet. App. 247 (1999); Caluza v. Brown, 7 Vet. App. 498 (1995), aff’d per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran. 38 U.S.C. § 5107(b). The Veteran provided a detailed statement explaining all the physical duties and physical demands required when he served in the United States Army Special Forces (Airborne). He was required to run several miles and participate in “ruck-running” several times a week with a 60 lb ruck sack while carrying his weapon. He would climb mountains and jump out of planes with a full combat load that weighed approximately 150 lbs. See July 2015 Correspondence. The record shows a current diagnosis of shoulder impingement syndrome of the bilateral shoulders with the diagnosis date listed as 1985. See December 2015 VA Shoulder and Arm Conditions Disability Benefits Questionnaire (DBQ). The record also reflects a current diagnosis of trochanteric pain syndrome of the right hip. See December 2015 VA Hip and Thigh Conditions DBQ. The September 1981 entrance examination shows that the Veteran was healthy upon entrance. It is not in dispute that the Veteran’s military occupational specialty (MOS) was a Special Operations Engineer Sergeant and that he received several medals, badges, and ribbons to include Parachutist Badges, an Army Achievement Medal, and an Army Good Conduct Medal. See DD-214. The December 2015 VA examiner provided opinions related to the bilateral shoulder disability and the right hip disability. He opined that neither disability was related to service. The rationale provided was that there was no evidence of a shoulder condition or right hip condition in the service treatment records. The examiner knew of no medical authority or peer reviewed medical literature indicating that parachuting causes impingement syndrome as it is generally the result of repetitive overhead use. The examiner also stated that trochanteric bursitis is the result of prolonged walking and running and is not associated with parachuting. A board-certified physician assistant provided a written statement, dated June 2019. She has been serving as a Physician Assistant in the U.S. Army Reserve since 2009. She indicated that she has reviewed the Veteran’s medical history and x-rays, as has noted the circumstances and events from his military service. She described the symptoms of the bilateral shoulder disability and the right hip disability. She described the physical duties the Veteran performed while in service. She citied to two studies and a research paper, all discussing the relation to shoulder impingement and serving in the Army. She also cited to two studies that discussed musculoskeletal injuries and trochanteric bursitis as a chronic condition. The board-certified physician assistant opined that it is as least as likely than not that the Veteran’s bilateral shoulder impingement disability and the right hip disability are service connected. She went on to say that the Veteran’s duty MOS as a Special Forces Operator and the high level of demand to maintain peak performance are consistent with the musculoskeletal injuries he is suffering. His duty MOS and injury pattern are consistent with chronic overuse injuries that likely was sustained during his time serving with the Special Forces Unit. The medical literature supports his claims and these findings. He has required ongoing treatment for his injury and will unlikely be fully rehabilitated. There are two probative medical opinions of record regarding the bilateral shoulder disability and the right hip disability. One is positive and the other negative. Both clinicians are competent to provide the opinions, and the Board has no reason to question their credibility. As the evidence for and against the claims are in relative equipoise, service connection for bilateral shoulder disability and service connection for right hip disability is granted. REASONS FOR REMAND The Veteran provided competent and credible testimony regarding his in-service injury to his left ankle, as well as the symptoms related to his left ankle disability. December 1986 service treatment records show injury to the left ankle. The Board recognizes that the evidence in the file does not reflect an actual current diagnosis of a left ankle disability. However, given the Veteran’s contentions and the in-service documentation the Board finds that the minimal threshold has been met to warrant a VA examination. As such, the Board finds that a remand is required to provide an examination to verify the current diagnosis, to include any functional impairment in the left ankle joint. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). The matter is REMANDED for the following action: The AOJ should schedule an appropriate VA examination to determine the nature and etiology of the Veteran’s left ankle disability. Following review of the claims file and examination of the Veteran, the examiner should provide opinions that respond to the following: (a.) Does the Veteran currently have a diagnosis of a left ankle disability at any time during the appeal period (from December 2015)? Note: pain in and of itself may constitute a disability for VA purposes if it results in functional impairment. (b.) If a medical diagnosis cannot be given, the examiner must state whether the Veteran has any functional impairment, such as loss of range of motion, pain, or instability. (c.) For each diagnosed left ankle disability or finding of functional impairment, the examiner should provide an opinion regarding whether it is at least as likely as not (i.e., probability of 50 percent) that the disability manifested during active service; or is otherwise related to an event, injury, or disease incurred during active service, to include the physically demanding duties that come with serving in the Army Special Forces (Airborne). Review of the entire file is required; however, the examiner is asked to review and specifically comment on the December 1986 radiologic consultation report, and the December 1986 service treatment record, both noting injury to the left ankle (VBMS, document labeled STR-Medical, receipt date June 10, 2015, pgs. 48 and 56 of 79). (Continued on the next page)   The examiner is asked to provide a detailed rationale for any opinions reached. H.M. WALKER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Talamantes, 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.