Citation Nr: 21026468 Decision Date: 05/03/21 Archive Date: 05/03/21 DOCKET NO. 17-04 136 DATE: May 3, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disability, to include adjustment disorder with anxiety and posttraumatic stress disorder (PTSD), is remanded. Entitlement to service connection for a right hip disability is remanded. REASONS FOR REMAND The Veteran served on active duty from June 2004 to November 2005. His service personnel records (SPRs) also reflect that he had several periods of active duty for training (ADT) and inactive duty for training (IDT), including annual training, nearly every year between April 6, 1999 and March 3, 2012. The Veteran testified before the undersigned Veterans Law Judge via video conference in February 2021. A transcript of the hearing is associated with the claims file. 1. Entitlement to service connection for an acquired psychiatric disability, to include adjustment disorder with anxiety and posttraumatic stress disorder (PTSD) is remanded. During the February 2021 hearing, the Veteran testified that he received treatment for his mental health disability at the Vet Center in approximately 2009 or 2010 before he sought treatment from the Boise VA Medical Center (VAMC) in 2012. However, the Veteran's claims file does not contain records from the Vet Center or treatment records from Boise VAMC prior to July 2014. Therefore, a remand is needed to obtain all outstanding treatment records. In addition to the foregoing, the Board finds a new VA examination is needed to clarify whether the Veteran has a psychiatric disability that was incurred during or as a result of his active service. In this regard, the evidence shows that, during a September 2011 VA examination, the Veteran was diagnosed with adjustment disorder with anxiety which the examiner stated appeared to resolve. The examiner also stated that, while he had some mild PTSD symptoms, the Veteran did not meet the DSM-IV criteria for a diagnosis of PTSD. However, the Veteran testified that he requested the VA examiner not render a diagnosis of PTSD due to a pending custody dispute, and the other evidence of record shows he continues to experience various psychiatric symptoms and has been variously diagnosed with PTSD and depression during outpatient treatment. See e.g., November 2014 VA treatment record. The Board further notes that the September 2011 VA examiner conducted her mental status evaluation pursuant to the DSM-IV, which was applicable at that time; however, the newer DMS-5 criteria apply in this case, as the Veteran's appeal was certified to the Board after August 4, 2014. 2. Entitlement to service connection for a right hip disability is remanded. During the February 2021 hearing, the Veteran testified that he had one injury to his hips while deployed to Iraq, but he also testified that, every time he performed physical training and heavy impact exercises during subsequent periods of training, he expereinced hip pain for which he eventually received physical therapy. The Veteran's service treatment records (STRs) confirm that he sought treatment for lower and mid-thoracic back pain after slipping while lifting heavy tents during active service in Iraq. At that time, he reported that his back pain radiated into his right hip and mid-thigh and was also manifested by right side weakness. The diagnostic assessment at that time was lumbar strain. See August 2005 STR. The medical evidence also shows that the Veteran subsequently reported having pain in his low back, hips, and right sacroiliac joints as early as April 2006, with subsequent similar complaints after running, doing guerilla drills, and "combatives" during periods of training. See e.g., VA treatment records dated April, May, and August 2006. Following examination in May 2014, a VA physician opined that it is less likely that the Veteran's current right hip degenerative joint disease is related to the single transient episode of right hip pain reflected in the STRs, noting that chronic femoral acetabular impingement (which was also found on x-ray tests) is typically a persistently symptomatic condition which he noted was not found in the STRs. The May 2014 VA opinion is deemed inadequate because the VA examiner did not consider the evidence showing continued complaints of hip pain and problems in 2006 and thereafter, which the Board notes includes periods the Veteran was likely on ADT or IDT. See September 2012 Army National Guard Retirement Points Statement. Therefore, a remand is needed for a new VA opinion. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records from the Boise VAMC, including records from the Vet Center, dated from 2009 to the present. All efforts to obtain such records should be documented in the claims folder. All available records should be associated with the Veteran's VA claims folder. 2. Schedule the Veteran for a VA mental health examination. After examining the entire record, the examiner should provide the following opinions: (a) Based upon the DSM-5 criteria, provide a diagnosis of any psychiatric disability manifested upon examination. If no diagnosis is rendered, the examiner must reconcile his/her findings with the diagnoses reflected in the record. (b) For each psychiatric disability identified above, opine whether it is at least as likely as not (50 percent or higher degree of probability) that the disability was incurred during or as a result of the Veteran's military service, including any traumatic events reported by the Veteran during deployment to Iraq or subsequent periods of training. (c) The examiner must specifically state whether the Veteran has a diagnosis of PTSD. Regarding a diagnosis of PTSD, provide an opinion as to whether the stressful events reported by the Veteran are related to a fear of hostile military or terrorist activity or, otherwise, to stressors that have been corroborated. (d) In answering the foregoing, the examiner must address the lay and medical evidence of record and provide a clear rationale for each opinion offered. 3. Request that an appropriate medical professional review the claims file and provide an addendum opinion regarding the Veteran's right hip disability. After reviewing the record, the examiner should opine whether it is at least as likely as not (i.e., whether it is 50 percent or more probable) that the Veteran's current right hip disability was incurred during or as a result of active service. In answering the foregoing, the examiner must consider the Veteran's complaints of right hip pain during active service in August 2005, as well as his complaints of right hip pain and problems following physical training and activities performed during National Guard service, which included periods of active and inactive duty for training. A clear, well-reasoned rationale should be provided in support of any opinion offered. M. Donohue Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Turnipseed, 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.