Citation Nr: 21021676 Decision Date: 04/13/21 Archive Date: 04/13/21 DOCKET NO. 13-07 310 DATE: April 13, 2021 REMANDED 1. Entitlement to service connection for a right hip disability is remanded. 2. Entitlement to service connection for a left hip disability is remanded. REASONS FOR REMAND The Veteran served from November 1970 to November 1974, January 1975 to January 1978, and January 1978 to January 1981. These matters were previously remanded by the Board of Veterans’ Appeals (Board) in August 2020. The Board’s August 2020 remand directives and the subsequent actions of the AOJ will be discussed below. The Veteran’s appeal has been returned to the Board for further appellate consideration.  Entitlement to service connection for a bilateral hip disability is remanded. Although the Board regrets the delay, remand is necessary to ensure that there is a complete record on which to decide the Veteran’s claim for entitlement to service connection for bilateral hip pain. The Veteran was afforded a VA examination in January 2021. The examiner concluded the Veteran’s bilateral hip disability was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. He reasoned that there were no medical records showing a diagnosis, treatment, or any hip related condition while the Veteran was still in service. The examiner did however note that the Veteran complained of a pulled muscle in the left thigh, but ultimately concluded that this injury would not affect the hip. See January 2021 Right Hip VA examination; see also January 2021 Left Hip VA examination. The examiner found that there was no further documentation to support the Veteran’s claim of chronic bilateral hip pain. However, the examiner failed to consider the Veteran’s reported medical history. The Veteran testified in a March 2016 Hearing that he got hit a few times while playing football in service. He noted that he had pain when he was young in his hip, but it was a spasm. He reported that the older he gets, the longer the pain lasted. See March 2016 Hearing Transcript. Additionally, the Veteran reported in the March 2018 VA examination that he had hip pain prior to service and that his hip pain had worsened while in service. Further, the Veteran noted that he continued to have bilateral hip pain following service. See March 2018 VA examination. Further, the Veteran reported in the January 2021 examination that his condition began in 1976 with symptoms of hip pain and noted his condition had worsened over the years with current symptoms described as hip pain and stiffness. See January 2021 Bilateral Hip VA examination. The examiner implied that the presence of bilateral hip pain could not have existed without documentation; however, this fails to consider the Veteran’s statement that he has continuously had bilateral hip pain simply because the report of symptoms was not supported by contemporaneous medical evidence. Especially given no reason to reject the credibility of the lay statements, the Board finds the rejection of lay symptomatology to be in error. See Barr v. Nicholson, 21 Vet. App. 303, 310 (2007) (“The Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms.”). Moreover, the January 2021 examiner failed to address the Veteran’s report that his hip pain existed prior to service. The Veteran reported that this right hip disability preexisted service during the March 2018 VA examination. See March 2018 VA examination. The Veteran’s service treatment records reflect a diagnosis for right hip bursitis, which the Veteran reported began in high school prior to service. See June 2014 Service Treatment Record pp. 114, 118. The March 2018 and January 2021 examiner failed to consider the Veteran’s contentions and evidence that his right hip disability preexisted service and was aggravated by in-service events. Accordingly, the Board finds a remand for a new VA examination is warranted to determine the nature and etiology of the Veteran’s right hip condition. In sum, the Board finds that an additional examination is necessary in order to fully consider the evidence of record. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain an opinion, it must ensure that the examination or opinion is adequate). The matters are REMANDED for the following action: Return the file back to the January 2021 examiner (or another appropriate examiner if the January 2021 examiner is unavailable) to ascertain the nature and etiology of the Veteran’s bilateral hip disability. Any indicated evaluations, studies, and tests deemed necessary should be accomplished. After eliciting a history of the Veteran’s disability, the examiner should offer comments, an opinion, and a supporting rationale for the following: (a.) With regard to the Veteran’s right hip disability claim, the VA examiner should offer the following opinion: 1. Was the preexisting right hip condition clearly and unmistakably not aggravated by the Veteran’s service? The examiner should note the Veteran had a diagnosis for right hip bursitis from high school. See June 2014 Service Treatment Record pp. 114, 118. Clear and unmistakable evidence is evidence that is obvious, manifest, and undebatable. The term “aggravated” in this context refers to a permanent worsening of the underlying condition beyond the natural progress of the disease, as contrasted to temporary or intermittent flare-ups of symptomatology that resolve with a return to the baseline level of disability. If clear and unmistakable evidence is found, the VA examiner should cite to factual data contained in the record or medical literature to support such a conclusion. In providing the opinion, the examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be considered. If the examiner rejects the Veteran’s reports, the examiner must provide a reason for doing so. 2. If it is the examiner’s opinion that there is no clear and unmistakable evidence that the right hip condition was not aggravated by service, the Veteran is presumed sound at service entrance, and the question becomes one of direct service connection. In this case, the VA physician is requested to answer to the following question: Is it as least as likely as not (a 50 percent or greater probability) that the right hip condition had its onset during active service, or is otherwise related to active service? The examiner must address the Veteran’s contention that he was hit a few times while playing football during service which caused initial hip pain and that he continued to have bilateral hip pain following service. See March 2016 Hearing Transcript; see also March 2018 VA examination. (b.) With regard to the Veteran’s left hip disability claim, the VA examiner should offer the following opinion: 1. Is it as least as likely as not (a 50 percent or greater probability) that the left hip condition had its onset during active service, or is otherwise related to active service? The examiner must address the Veteran’s contention that he was hit a few times while playing football during service which caused initial hip pain and that he continued to have bilateral hip pain following service. See March 2016 Hearing Transcript; see also March 2018 VA examination. In rendering the requested opinions, the examiner is advised that a full rationale must be provided for all medical opinions given. If the examiner is unable to provide an opinion without resorting to mere speculation, he or she should explain why this is so. The examiner shall then explain whether the inability to provide a more definitive opinion is the result of a need for more information and indicate what additional evidence is necessary, or whether he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). D. C. JOHNSON Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Emily A. Kotroco 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.