Citation Nr: 18150170 Decision Date: 11/14/18 Archive Date: 11/14/18 DOCKET NO. 16-35 880 DATE: November 14, 2018 REMANDED Entitlement to service connection for a left hip condition, to include as secondary to the service-connected lumbosacral strain, is remanded. Entitlement to service connection for a left knee condition is remanded. Entitlement to service connection for a right knee condition is remanded. Entitlement to an initial rating in excess of 10 percent for lumbosacral strain (claimed as a lower back condition) is remanded. REASONS FOR REMAND The Veteran had active duty service from May 2011 to December 2014. His military awards and decorations include the Combat Action Ribbon and the Afghanistan Campaign Medal with One Star. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from April 2015 and August 2015 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO).   1. Entitlement to service connection for a left hip condition, to include as secondary to the service-connected lumbosacral strain, and a bilateral knee condition is remanded. The Veteran contends that he has a left hip condition and bilateral knee condition as a direct result of his active duty service. Specifically, he states he initially injured his hip during his School of Infantry (SOI) training. See Correspondence, September 2015. He also asserts that his bilateral knee condition is consistent with his military occupational specialty of machine gunner. In this regard, the Boards notes that it is documented in the claims file that while on patrol the Veteran’s vehicle was struck by an IED while he was in the turret. See VA 21-0781, July 2016. Finally, a review of the Veteran’s postservice treatment records shows that upon complaining of pain in the left hip, his treatment provider noted that this pain could be referred from the lower back to the hip. See Durham VA Medical Center Primary Care Initial Evaluation Note, February 2015. Accordingly, the Board finds that the Veteran’s service connection claim for the left hip should also be considered as secondary to his service-connected lumbosacral strain. The Veteran has not yet been afforded a VA examination in these matters. Although his postservice treatment records are silent for any diagnoses related to the left hip and bilateral knee, he has described having continuous pain in his left hip and bilateral knees since service. Accordingly, the Board finds VA’s duty to assist is triggered and that remand is warranted for a VA examination to determine whether the Veteran has a left hip and/or bilateral knee disability and, if so, whether it is related to his combat-related active duty service. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006) 2. Entitlement to an initial increased rating in excess of 10 percent for lumbosacral strain (claimed as a lower back condition) is remanded. The Veteran seeks an increased rating for his service-connected lumbosacral strain. The Veteran was most recently afforded a VA examination to evaluate his back disability in July 2017. However, the examiner did not illicit any information regarding precipitating or alleviating factors pertinent to flare-ups. Nor did the examiner offer an opinion estimating the extent of the Veteran’s functional impairment during flare-ups based upon the information gleaned from the examination and the Veteran’s claims file. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the United States Court of Appeals for Veterans Claims (Court) addressed the adequacy of a VA examiner’s report when providing an opinion regarding functional loss during flare-ups of a musculoskeletal disability, pursuant to DeLuca v. Brown, 8 Vet. App. 202 (1995). The Court held that before a VA examiner opines that he or she cannot offer an opinion as to additional functional loss during flare-ups without resorting to speculation based on the fact that the examination was not performed during a flare, the examiner must “elicit relevant information as to the veteran’s flares or ask him to describe the additional functional loss, if any, he suffered during flares and then estimate the veteran’s functional loss due to flares based on all the evidence of record, including the veteran’s lay information, or explain why she could not do so.” See Sharp, 29 Vet. App. at 33. The Board finds that the July 2017 VA examination is inadequate for rating purposes because it does not provide the required information regarding functional limitations caused by flare-ups and fails to adequately explain why an opinion regarding functional limitations, including an estimate of range of motion during flare ups, was not provided. Furthermore, subsequent to the July 2017 VA examination, the Veteran submitted disks of X-rays suggesting that his back disability had worsened. See NOD, August 2017. Accordingly, the Board finds that remand is warranted for further records development and a new VA examination to evaluate the nature and severity of the Veteran’s back disability. The matters are REMANDED for the following actions: 1. Contact the Veteran and afford him the opportunity to identify by name, address and dates of treatment or examination any medical records relevant to his back, left hip and bilateral knee disabilities, to specifically include the reports associated with the spinal X-ray conducted in August 2017. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already in the record. 2. After all available records are associated with the claims file, afford the Veteran an appropriate VA examination to determine the nature and etiology of his claimed left hip and bilateral knee conditions. The entire claims file must be made available to and be reviewed by the examiner. All necessary tests should be completed. An explanation for all opinions expressed must be provided. The examiner should provide an opinion responding to the following: (a.) Does the Veteran have (or has he had at any point during the appeal period, i.e., from May 2015) a diagnosed left hip disability, left knee disability, or right knee disability? (b.) For every left hip disability diagnosed, is it at least as likely as not (50 percent or better probability) etiologically related to his active service, to include his hip injury during SOI training as well as any other injuries that may have resulted from his combat service as a machine gunner? (c.) For every left hip disability diagnosed, it at least as likely as not (50 percent or better probability) caused by his service-connected back disability? (d.) For every left hip disability diagnosed, it at least as likely as not (50 percent or better probability) aggravated by (worsened beyond its natural progression) by his service-connected back disability? (e.) For every left and right knee disability diagnosed, is it at least as likely as not (50 percent or better probability) etiologically related to his active service, to include any injuries that may have resulted from his combat service as a machine gunner? 3. Then schedule the Veteran for a VA back examination to assess the nature and current severity of his service-connected lumbosacral strain. All indicated evaluations, studies, and tests deemed to be necessary should be accomplished. The examiner should cite to the medical and competent lay evidence of record and explain the rationale for all opinions given. (a.) The examiner should identify all lumbar spine pathology found to be present. The examiner should conduct all indicated tests and studies, to include range of motion studies. Full range of motion testing must be performed where possible. The joint involved should be tested in both active and passive motion, in weight-bearing and non-weight-bearing. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. (b.) The examiner should describe any pain, weakened movement, excess fatigability, instability of station and lack of coordination present. (c.) The examiner should also state whether the examination is taking place during a period of flare-up. If not, the examiner should ask the Veteran to describe the flare-ups he experiences, including: frequency, duration, characteristics, precipitating and alleviating factors, severity and/or extent of functional impairment he experiences during a flare-up of his lumbar spine symptoms and/or after repeated use over time. Based on the Veteran’s lay statements and the other evidence of record, the examiner should provide an opinion estimating any additional degrees of limited range of motion caused by functional loss during a flare-up or after repeated use over time. (d.) If the examiner cannot estimate the degrees of additional range of motion loss during flare-ups or after repetitive use without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). The examiner should note that the VA CLINICIAN’S GUIDE requires the examiner to estimate the range of motion “per [the] Veteran.” See VA CLINICIAN’S GUIDE at Ch. 11. A. ISHIZAWAR Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Alexander, Associate Counsel