Citation Nr: 21022493 Decision Date: 04/16/21 Archive Date: 04/16/21 DOCKET NO. 16-24 709 DATE: April 16, 2021 REMANDED Entitlement to service connection for residuals of a right thigh contusion, claimed as a right leg/thigh injury, is remanded. REASONS FOR REMAND The Veteran, who is the appellant, had active service from July 1985 to December 1988. The Veteran maintains that he sustained an injury to his right thigh as a result of a large object being dropped on it in 1986. Service treatment records reveal that the Veteran sustained trauma to his right thigh in November 1986 when an ammunition round was dropped on his right thigh. Physical examination revealed a right thigh contusion. A diagnosis of R/O fracture right thigh was rendered at that time. At the time of a followup visit, a diagnosis of a contusion/soft tissue injury was rendered. In October 1988, the Veteran requested that he be afforded an x-ray for his right leg. The Veteran reported that he had dropped a 275 lb object on his leg in September 1986 and that it left a dent/hole in his leg. Physical examination revealed a “hole or dent” in the right leg. There was also a defect in the rectus/femoris noted. X-rays revealed a cortical deficit at the site of the old blunt trauma. The Veteran was afforded a VA examination in March 2013. A diagnosis of a right thigh contusion in November 1986 was rendered at that time. The examiner indicated that he had reviewed the entire claims folder, including VA treatment records. X-rays of the area were not performed. Following examination of the Veteran and review of the folder, the examiner opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner stated that it was his medical opinion that the Veteran's condition of history of remote right thigh contusion since healed without residuals was less likely than not (less than 50 percent probability) caused by or related to the condition treated for in service since there was no condition of right thigh contusion. He indicated that the Veteran's remote right thigh contusion was a temporary condition that was treated and had since healed without residuals. He stated that the Veteran’s complaints were not chronic and disabling since he had not sought medical care for them or made complaints to his treating examiners since active duty service. In his April 2021 informal hearing presentation, the Veteran’s representative indicated that although the Veteran underwent a VA examination, there were no post-service records available from any source and it did not appear that he had any reserve service. It was noted that the Veteran told the examiner that the artillery round he was carrying weighed “about 350lb.” It did not appear that there was any limitation of motion. The Veteran also complained of a “throbbing pain” in his leg but apparently had not had any post-service treatment. He had a small, round indentation on the right thigh that was not painful or adherent. The examiner noted that the Veteran was self-employed as a roofing and siding contractor and there were no employment limitations. The examiner opined that the in-service condition was a temporary one that healed without residual. The representative indicated that the Veteran complained of arthritis, but no x-rays were taken. He stated that given the Veteran’s complaints of arthritis, the examiner should have ordered an x-ray to determine if any existed. Since that was not accomplished, the examination was inadequate. Also, the examiner stated that he reviewed VA treatment records, but there were none in the file. The representative stated that it was not clear whether he reviewed records pertaining to the Veteran or whether he reviewed VA treatment records generally to see whether any existed on the Veteran. The representative stated that in view of the above, and given the VA’s duty to exist and ensure the adequacy of its examinations, the appeal should be remanded for x-rays of the leg and so the RO could contact the hospital and determine whether there any VA treatment records available for the Veteran. The Board does note there are there are no VA treatment records located in the claims folder. The Board further observes that at the time of the October 1988 inservice visit, physical examination revealed a “hole or dent” in the right leg and a defect in the rectus/femoris. X-rays taken revealed a cortical deficit at the site of the old blunt trauma. Given the above, the Veteran should be afforded an additional VA examination, to include x-rays, and an attempt should be made to obtain all treatment records, VA and private. The matters are REMANDED for the following action: 1. Undertake appropriate development to obtain all outstanding VA and/or private treatment records related to the Veteran's outstanding claim. If any requested records are not available, the record should be annotated to reflect such and the Veteran notified. If there are no VA records available, it should be so stated. 2. Schedule the Veteran for an appropriate VA examination to determine the nature and etiology of any current right thigh injury residuals, to include arthritis, if present. All indicated tests and studies, including x-rays, should be performed and all findings should be reported in detail. The entire record should be made available to the examiner. The examiner is requested to offer the following opinion: Is it as likely as not (50 percent probability or greater) that any current right thigh/leg injury residuals, to include arthritis, if found, are etiologically related to the Veteran's period of active service? When rendering the above opinion, the examiner should comment and address the findings made at the time of the October 1988 inservice visit, at which time physical examination revealed a “hole or dent” in the right leg with a defect in the rectus/femoris being noted. X-rays taken at that time also revealed a cortical deficit at the site of the old blunt trauma. Complete detailed rationale is requested for each opinion that is rendered. K. Parakkal Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. S. Kelly, 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.