Citation Nr: 20022492 Decision Date: 04/01/20 Archive Date: 04/01/20 DOCKET NO. 16-23 246 DATE: April 1, 2020 REMANDED Entitlement to service connection for right hip strain is remanded. REASONS AND BASIS FOR REMAND The Veteran served on active duty in the Army from September 2007 to July 2011. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a February 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) (hereinafter Agency of Original Jurisdiction (AOJ)) in Waco, Texas. In May 2018, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearings is of record. In September 2018, the Board remanded the appeal for further development. Specifically, the Board directed the RO to attempt to obtain additional medical records and to obtain medical opinions of the etiology of the Veteran’s claimed left ankle and thyroid disabilities. These directives have been completed. In a January 2020 rating decision, the AOJ granted the Veteran’s claims for service connection for a left ankle disability and a thyroid disability. These awards constitute a full grant of the disability sought, and those appeals have been resolved. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997) (holding that where an appealed claim for service connection is granted during the pendency of the appeal, a second notice of disagreement must thereafter be timely filed to initiate appellate review of the claim concerning “downstream” issues, such as the compensation level assigned for the disability and the effective date). The Veteran reports that she has a chronic right hip condition that began in service. Specifically, she reports that she has had right hip pain since falling on black ice in 2008. A review of the record illustrates this claim has been developed solely as a claim for service connection for a right hip condition as secondary to her lower back disability. However, as noted above, the Veteran has reported that she injured her right hip in a fall during service. The record reflects a current diagnosis of right hip pain. The Board cannot make a fully-informed decision on the issue because no VA examiner has opined whether the Veteran's right hip condition is related to service. In an April 2014 opine provided by a family nurse practitioner (FNP), the FNP opined that I have reviewed her medical records. In my opinion, the right hip pain is related to low back pain which is more likely than not caused by an injury during military service. The Board finds the April 2014 FNP opinion inadequate for adjudication purposes. In this regard, the examiner did not adequately provide supporting rationale for the opinion provided. As the opinion is not adequate, it cannot serve as the basis for adjudicating the issue of entitlement to service connection. In a March 2016 VA examination, the examiner determined that the Veteran did not have a right hip condition. The examiner opined that the Veteran’s low back condition did not cause her claimed hip strain. The examiner stated that There is no literature that supports low back strain causes hip strain. Therefore, the claimed right hip strain is not at least as likely as not (less than 50 percent probability) proximately due to or the result of low back strain. The Board finds the March 2016 VA opinion inadequate for adjudication purposes. In this regard, the examiner did not adequately provide supporting rationale for the opinion provided, nor give appropriate consideration to the Veteran's lay statements regarding the onset and continuity of her symptoms as documented in her post-service treatment records. Additionally, the examiner did not give adequate consideration to the diagnoses of right hip pain contained in the Veteran’s post-service treatment records, nor provide an opinion on the Veteran’s right hip condition on a direct basis. As the opinion is not adequate, it cannot serve as the basis for adjudicating the issue of entitlement to service connection. In a January 2020 private evaluation and opinion, the examiner stated that The initial injury involved a slip and fall on the buttocks with force of impact likely affecting pelvis, sacroiliac joints, lumbosacral joints and possibly lumbar spine disks… Initial medical diagnoses included suspicion of sacroiliac involvement with evidence of sacroiliitis. Initial diagnostic imaging did not include any positive findings involving the right hip joint. Onset of right hip joint pain was between 4 and 5 years following the incident of falling onto the buttocks. It is not reasonable to consider onset of right hip pain as casually related to a slip and fall onto the buttocks 4 to 5 years earlier, so the timeline does not support causation. The absence of diagnostic imaging findings to reveal acute injury or chronic posttraumatic changes to the acetabular labrum, femoral head or cartilage interval is also a non-supportive factor. While injury to the lower spine and sacroiliac joints may tend to affect posture and gait patterns, I couldn’t find supportive evidence in the medical records between the date of injury and date of onset of hip pain. She was diagnosed with psoriasis and associated arthropathy about a year following the onset of hip pain, lending suspicion that the disease may be contributing to her hip pain. There also may have been other military-related stresses and strains with cumulative force of impact to the right hip resulting in her present painful condition. While symptoms in the right hip area may be associated with altered biomechanics of the lumbar spine, lumbosacral joint, and/or sacroiliac joints, I do not find enough evidence to support causation of right hip joint injury as it might have been related to the November 2008 slip and fall on black ice. The Board notes that the Veteran is service-connected for xerosis cutis, claimed as psoriasis. The January 2020 examiner did not provide a conclusive finding on whether the Veteran’s service-connected xerosis cutis or psoriasis has caused or aggravated the Veteran’s right hip condition. Additionally, the examiner did not provide a conclusive finding on whether the Veteran’s service-connected lumbar condition has caused or aggravated the Veteran’s right hip condition. Rather, the examiner provided a negative opine on the issue of direct service connection related to the claimed November 2008 injury. As such, this opinion is inadequate on the issue of secondary service connection. The Board notes that the Veteran has claimed entitlement to service connection for a right hip disability manifested based on a direct service connection theory of entitlement under 38 C.F.R. § 3.303 and on a secondary service connection theory of entitlement under 38 C.F.R. § 3.310. The Board is required to address all theories of entitlement reasonably raised by the record. Robinson v. Peake, 21 Vet. App. 545 (The Board commits error...in failing to discuss a theory of entitlement that was raised either by the appellant or by the evidence of record). However, the opinion of the January 2020 examiner raises the issue of secondary service connection based on the Veteran’s service-connected lumbar and xerosis cutis disabilities. The Board must therefore consider whether the Veteran's right hip disability is secondary to her service-connected lumber and xerosis cutis, claimed as psoriasis, conditions. Thus, the Board finds that a remand is necessary to obtain a new medical opinion that addresses the disparate medical evidence and the secondary service connection theory of entitlement raised by the record. For the reasons explained below, and after careful consideration of the evidence of record, the Board finds that the Veteran's right hip disability may be a manifestation of her service-connected xerosis cutis, and a VA opinion on this issue is required. The matters are REMANDED for the following action: 1. Obtain and associate with the record all VA and private treatment records for the Veteran. All actions to obtain the requested records should be fully documented in the record. If they cannot be located or no such records exist, the Veteran and his representative should be so notified in writing. 2. Obtain an opinion from an appropriate clinician regarding whether it is at least as likely as not (i.e., probability of 50 percent or greater) that the Veteran's right hip disorder had its clinical onset during active service or is aggravated by or otherwise related to any in-service disease, event, or injury, to include the Veteran’s thoracolumbar disorder, xerosis cutis and left ankle disorder. The examiner must review the Veteran's claims file and elicit a full history from the Veteran regarding his symptoms of his right hip disorder. All necessary tests and studies should be accomplished, and all clinical findings should be reported in detail. After the record review, and a thorough examination and interview of the Veteran, the VA examiner should provide an opinion on the following questions: a. It is at least as likely as not (50 percent or greater probability) that any right hip disorder was caused by, or results from either or all her service-connected thoracolumbar disorder, xerosis cutis and left ankle disorders? b. It is at least as likely as not (50 percent or greater probability) that any right hip disorder was aggravated due to or as the result of either of all her service-connected thoracolumbar disorder, xerosis cutis and left ankle disorders? c. Is any diagnosed right hip condition a symptom of her service-connected thoracolumbar disorder, xerosis cutis and left ankle disorders? The examiner is asked to address the following: ** The Veteran’s contentions regarding having problems with her right hip after an injury in service in 2008. ** The April 2014 opinion that the Veteran’s right hip pain is related to low back pain which is more likely than not caused by an injury during military service. ** The January 2020 private evaluation and opinion that the Veteran’s psoriasis and associated arthropathy may be contributing to her hip pain. ** Findings of sacroiliitis. ** Chiropractic treatment notes indicating a sacroiliac joint condition. ** Diagnosis of xerosis cutis or psoriasis. The examiner must include the underlying reasons for any conclusions reached. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. 3. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran’s claims should be readjudicated based on the entirety of the evidence. If any benefit sought remains denied, the Veteran and her representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. T. MAINELLI Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Michael J. O’Connor 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.