Citation Nr: 18153206 Decision Date: 11/27/18 Archive Date: 11/27/18 DOCKET NO. 15-33 927 DATE: November 27, 2018 REMANDED ISSUES The issue of entitlement to service connection for right hip disability, to include as secondary to service-connected ankle disabilities, is remanded. The issue of entitlement to an initial compensable evaluation for chronic peroneus brevis tendinopathy, right ankle, prior to June 29, 2012, and in excess of 10 percent from that date, is remanded. The issue of entitlement to an initial compensable evaluation for chronic peroneus brevis tendinopathy, left ankle, prior to June 29, 2012, and in excess of 10 percent from that date, is remanded. The issue of entitlement to a 10 percent evaluation based upon multiple, noncompensable service-connected disabilities for the period prior to June 29, 2012, is remanded. REFFERED The issue of entitlement to service connection for depression, as secondary to service-connected ankle disabilities, was raised in April 2014 and September 2015 statements from the Veteran, and is referred to the Agency of Original Jurisdiction (AOJ) for adjudication. REASONS FOR REMAND The Veteran served on active duty from January 1979 to July 1984. The Board cannot make a fully-informed decision on the right hip claim because no VA examiner has adequately opined whether the Veteran’s service-connected ankle disabilities aggravate his right hip disability. Additional examinations are needed to adequately evaluate the service-connected ankle disabilities. The August 2018 VA Ankle Conditions Disability Benefits Questionnaire (DBQ) did not include a review of the Veteran’s medical or other records. As a result, the DBQ provides an incomplete and incorrect description of the Veteran’s ankle disabilities, and an inadequate medical opinion about their functional impact. The DBQ relates that no imaging studies of the ankle have been performed, but the Veteran underwent x-rays of the ankle in December 2010. The DBQ also relates that the Veteran did not use any assistive devices such as a cane; however, a June 2012 VA examination reflects that the Veteran regularly used a cane, due to his ankles. VA treatment records dated in April and September 2014 reflect that the Veteran was ambulant with a cane. Further, in April 2014 and September 2015, the Veteran related that he used a cane because his ankles give out, indicating instability. Finally, despite the Veteran’s documented use of a cane, the DBQ relates that ankle instability was not suspected and therefore not tested. The Veteran’s claim for a 10 percent evaluation based upon multiple, noncompensable service-connected disabilities is inextricably intertwined with the issues being remanded. See Harris v. Derwinski, 1 Vet. App. 180 (1991). The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination to obtain a medical opinion to the nature and etiology of any right hip disability. Copies of all pertinent records should be made available to the examiner for review. Based on the examination and review of the record, the examiner is to address the following questions: (a) Identify all currently diagnosed right hip disabilities. (b) Is it at least as likely as not (a 50 percent or greater probability) that any currently diagnosed right hip disability had its onset in or is otherwise related to the Veteran’s active duty service, to include the documented episodes of pelvic pain? (c) If the examiner finds that any diagnosed right hip condition is not related to service, is it is at least as likely as not that any currently diagnosed right hip disability is caused or aggravated to a service-connected ankle disability? The examiner is informed that aggravation here is defined as any increase in disability. If aggravation is present, the clinician should indicate, to the extent possible, the approximate level of disability (baseline) before the onset of the aggravation. A complete rationale must be provided for any opinion offered. 2. Schedule the Veteran for an examination to determine the current severity of his right and left ankle disabilities. The examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. To the extent possible, the examiner should identify any symptoms and functional impairments due to the ankle disabilities and discuss the effect of the ankle disabilities on any occupational functioning and activities of daily living. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). M.E. Larkin Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Davitian, Counsel