Citation Nr: 21041588 Decision Date: 07/09/21 Archive Date: 07/09/21 DOCKET NO. 17-06 276 DATE: July 9, 2021 REMANDED Entitlement to service connection for a right hip disorder, to include residuals of a right hip dislocation, is remanded. REASONS FOR REMAND The Veteran served on active duty from December 1988 to August 2013. The Department of Veterans Affairs (VA) is grateful for his service. Entitlement to service connection for a right hip disorder, to include residuals of a right hip dislocation, is remanded. The Board previously remanded the claim in December 2018. As the Board then noted, pain and associated functional impairment as identified upon recent VA examination implicated current disability for which service connection may potentially be granted, citing Saunders v. Wilkie, 886 F.3d 1356, 1364 (Fed. Cir. 2018). Regrettably, as discussed below, requested remand development is inadequate, necessitating remand again. In his Notice of Disagreement received in October 2014, the Veteran explained that he was never seen for an initial VA disability examination because he had started a new job and had to cancel the scheduled examination. The Board notes that the Veteran nonetheless submitted his appealed claim for a right hip disability manifested by pain prior to his separation from service. Service records reveal that the Veteran was seen in September 2011 for status post dislocation of the right hip, with x-rays obtained revealing normal alignment and no fracture of the right hip. However, it was then recommended that an MRI of the hip be considered based on the Veteran's clinical history of dislocation. An MRI is not reflected in service treatment records. In November 2016, a VA examiner provided an opinion against existence of a current right hip disability based on absence of objective evidence of hip disability upon examination. However, the examiner noted the Veteran's reported history of pain and lack of endurance limiting functional use of the right hip over time, and the examiner provided an estimated reduced range of motion as equivalent to this reported reduced functioning. The examiner also assessed moderate functional limitation with prolonged standing, walking, and sitting. Pursuant to the Board's December 2018 remand, the Veteran was afforded another examination in October 2019. X-rays of the hips revealed bilateral mild degenerative changes, but also revealed subchondral cystic change at the superior margin of the acetabulum on the right which was not present on the left. Limitation of motion of the hips was present. The examiner diagnosed bilateral degenerative arthritis of the hips and provided an opinion that it was not at least as likely as not that the Veteran's right hip disorder was incurred in service or caused by an in-service injury, event, or illness. The examiner provided a rationale that the Veteran's service records were silent for further right or left hip complaints following the 2011 dislocation. The Board finds this October 2019 examination opinion not probative based on its rationale relying on an incorrect statement of facts. Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) (per curiam). Service treatment records include a brief notation in an April 2013 treatment record informing that the Veteran would like to discuss medical conditions including "slight hip pain and swelling." Hence, service records were not "silent" about hip complaints following the 2011 dislocation. A new examination is accordingly required. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The October 2019 examiner additionally failed to address the recommendation of an MRI in service and failed to address whether the subchondral cystic change at the superior margin of the acetabulum on the right potentially reflected residuals of the hip dislocation in service. These should be addressed on remand. The examination should be conducted by an examiner qualified to address disabilities of the hips including subchondral cystic change at the superior margin of the acetabulum and their etiologies as potentially related to past injury or hip dislocation. The matter is REMANDED for the following actions: 1. Obtain any additional VA and pertinent private treatment records for association with the claims file. 2. Thereafter, obtain a new VA examination by an examiner qualified to address disabilities of the hips including subchondral cystic change at the superior margin of the acetabulum and their etiologies as potentially related to past injury or hip dislocation. The claims file must be reviewed in conjunction with the examination and any necessary tests or studies should be conducted. The examiner is to be advised that the prior examination in October 2019 was found non-probative because the examiner based an opinion on the incorrect assertion that there was no evidence of subsequent hip complaints in service records following initial treatment for right hip dislocation in 2011. In fact, an April 2013 treatment record documents the Veteran's complaint of slight hip pain and swelling. The examiner must also document and consider the Veteran's own statements regarding his disability, since a layperson is competent to address symptoms as experienced and his recollections of past history and treatment. If the examiner has reason based on other evidence of record or medical knowledge to question the Veteran's self-reported history, the examiner should so state and provide a complete explanation why this is so. In rending an opinion and providing a supporting rationale, the examiner should note multiple medical care visits in September 2011 for a right hip dislocation from a physical training incident, with a recommendation to consider an MRI, although service records do not reflect that an MRI was obtained. The examiner should note the Veteran's documented complaint of slight hip pain and swelling at an April 24, 2013 treatment. The examiner should also note the finding on x-rays of the hips in October 2019 of subchondral cystic change at the superior margin of the acetabulum on the right which was not present on the left. The examiner should additionally note that the Veteran submitted his current claim for a symptomatic right hip disability prior to his separation from service. The examiner must provide an opinion addressing whether it is at least as likely as not (50 percent or greater probability) that the Veteran has had a right hip disability within the claim period which was the result of an event, injury, or disease in service or which otherwise developed in service or was causally related to service. A complete rationale must be provided for any opinion expressed. (Continued next page) 3. Thereafter, readjudicate the appealed claim. L. CHU Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Schechter 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.