Citation Nr: 21064199 Decision Date: 10/19/21 Archive Date: 10/19/21 DOCKET NO. 18-32 813 DATE: October 19, 2021 REMANDED Entitlement to service connection for a left hip disability to include osteoarthritis is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1987 to February 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2017 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a Board videoconference hearing before the undersigned in April 2021. A transcript of that hearing is associated with the claims file. Entitlement to service connection for a left hip disability to include osteoarthritis is remanded. The Veteran asserts that his left hip disability is secondary to his left tibia disability. See Notice of Disagreement Received May 2017. The Veteran also asserts that the overwhelming medical evidence supports a finding of service connection for his left hip disability. Additionally, the Veteran reported that during the January 2018 DRO hearing, he was informed that another examination would be conducted in order for the examiner to consider whether his altered gait was due to his service connected right knee injury which he believes affects his left hip. See Form 9 Received June 2018. During the April 2021 hearing, the Veteran testified that he was diagnosed with left hip osteoarthritis in 2016 which he believes developed secondary to his altered gait due to him favoring his service-connected right knee condition and putting more stress on his left lower extremity. Additionally, the Veteran testified that his left hip disability has gotten progressively worse and he is forced to put weight on his right side in order to get around. The Veteran stated that his weight gain has also made it difficult, but indicated that he did not want to raise this as a theory of entitlement but instead referenced it as a side effect of his left hip diagnosis. Further, the Veteran testified that he began experiencing hip pain in 2013, shortly after he filed his claim for his right knee disability, but he kept dismissing it. The Veteran testified that he sees Dr. TS, his orthopedic specialist, for treatment of his left hip disability and was administered cortisone shots. The Veteran testified that Dr. TS informed him that his left hip disability is due to his altered gait that he has as a result of his knee and left leg fracture. The Veteran was afforded a hearing with a Decision Review Officer (DRO) in January 2018. During the hearing the Veteran stated that his left hip condition has worsened because due to his right knee condition he has had to shift his pressure and he favors his right side because of the arthritis and pain that he experiences in his leg. The Veteran also stated that he believes that his knee has caused him to have problems with his left hip. Additionally, the Veteran indicated that he has problems in his left knee and left leg due to a left leg fracture that he suffered during military service. The Veteran continuously emphasized that his left hip condition has consistently caused so much pain. The DRO stated that they would ask the physician to take another look at the record and provide an opinion on the Veteran's right knee. See Hearing Transcript Received January 2018. The Veteran's service treatment records (STRs) suggest that the Veteran's left hip injury may be related to injuries sustained during active duty service. A February 1988 STR states that the Veteran was admitted for acute back strain and at that time it was noted that the Veteran had slight decreased anterior flexion in the hips. The Veteran's STRs also indicate that the Veteran was involved in a motor vehicle accident in November 1987 and at the time he complained of pain in the left paraoevical region and over the left collarbone. Additionally, it is noted that the cervical spine was palpated and there was some discomfort of the left paracervical muscle region. Another treatment note dated May 1990 states that a radiologic report of the left tibia demonstrated marked periosteal thickening of the posterior aspect of the midshaft compatible with a healing stress fracture. A treatment note dated March 1991 states that the Veteran experienced a whiplash injury to the cervical spine that was incurred in a car accident in February 1991. The findings revealed that at the time, the Veteran experienced pain on rotation to the left and inclination and reclination occasionally. In a September 1990 treatment note it was stated that the Veteran had an arthroscopy of the right knee in August 1989 followed by surgical intervention on the lateral meniscus and diagnosed with a lesion of the medial meniscus of the right knee joint. Additionally, a November 1990 service treatment note states that a radiologic report showed that the Veteran's right knee displayed mild changes of osteoarthritis consisting of spurring of the medial posterior aspect of the patella, and what appears to be several loose bodies. The Veteran is currently service connected for degenerative joint disease of the right knee, left knee osteoarthritis, stress fracture of the left tibia, and right knee surgical scars associated with degenerative joint disease of the right knee. See Rating Decision Codesheet Received May 2018. The Veteran submitted treatment records from private physician Dr. TS concerning treatment for the Veteran's left hip and both knees. In a February 2018 treatment report, Dr. TS noted the history of the Veteran's condition and indicated that the Veteran experienced left hip pain. Dr. TS stated that the Veteran had severe pain in both knees and severe aggravating pain in his left hip. Additionally, Dr. TS stated that the Veteran had multiple previous injuries stemming from an injury while working in the military in 1989 and playing basketball. Additionally, it was noted that the Veteran injured both knees on separate occasions and he had right knee arthroscopy in 1989 and another one several years later. Dr. TS further stated that the Veteran injured his left lower leg and reported that he sustained a tibia fracture while playing basketball. Dr. TS noted that the Veteran has developed left hip arthritis, severe pain, and pain in his left groin that has gotten worse over the last several years. Dr. TS stated that radiographs of the left hip and pelvis demonstrate severe degenerative changes of the left hip. His assessment was that the Veteran had a right knee osteoarthritis from military injury, osteoarthritis of the left knee, and "compensatory progressive end stage osteoarthritis of the left hip." A May 2018 treatment report conducted by Dr. TS notes that the Veteran was treated with injections in his right knee and left hip. See Medical Treatment notes received June 2018. However, contrary to the Veteran's assertions during his hearing testimony and on his VA Form 9, Dr. TS. did not provide an etiological opinion on either occasion. The Veteran was afforded an examination for his left hip disability in December 2016. The examiner stated that the Veteran's advanced degenerative arthritis of the left hip on X-rays dated December 2016 was not proximately due to left tibial stress fracture in 1989. As rationale, the examiner stated that there is no scientific evidence to support the claim that advance degenerative arthritis of the left hip in 2016 is caused by self-limited stress fracture of the left tibia in 1989 without residuals. An addendum opinion was provided to address the Veteran's left hip osteoarthritis condition in April 2018. The April 2018 examiner opined that the Veteran's advanced left hip osteoarthritis reported on x-rays dated December 2016 is not proximately caused by or the result of degenerative arthritis of the right knee and not due to altered gait from residuals of stress fracture of the left tibia and DJD of the right knee. As rationale it was stated that left hip osteoarthritis is separate and unrelated to degenerative arthritis of the right knee and is also separate from residuals of stress fracture of the left tibia. The April 2018 examiner also opined that left hip strain can result from altered gait due to his service connected disabilities of residuals of stress fracture of the left tibia and degenerative arthritis of the right knee. As rationale, it was stated that left hip strain can develop from altered biomechanics due to service connected disabilities of residuals of stress fracture of the left tibia and degenerative arthritis of the right knee. The April 2018 examiner concluded that the range of motion of the left hip reported on the December 2016 DBQ is more likely than not due to advanced left hip osteoarthritis reported on x-rays and not due to left hip strain. Additionally, it was stated that advanced arthritis of the left hip reported on the December 2016 X-rays is not caused by or result of the left hip strain. The Board finds that another opinion is warranted in this case as it is not clear from the medical evidence and medical opinions of record whether the Veteran's left hip disability is a result of any of the injuries sustained during active military service or if the left hip injury was caused by or aggravated by any of his service-connected disabilities to include degenerative joint disease of the right knee, left knee osteoarthritis, stress fracture of the left tibia, and right knee surgical scars associated with degenerative joint disease of the right knee. The medical opinions offered are conflicting and unclear. Furthermore, the opinions of record do not contain adequate rationale to support the opinions offered and do not address aggravation. For an opinion to be adequate, it must include consideration of the Veteran's statements, be based on accurate factual premises, and contain a rationale sufficient to support its conclusions. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). VA must consider all lay and medical evidence of record. 38 U.S.C. § 1154(a); 38 U.S.C. § 5107; 38 C.F.R. § 3.303. Additionally, an opinion is needed to determine whether the left hip disability is caused or aggravated by the effects of the Veteran's service connected knee disabilities which resulted in an altered gait, to include addressing the statement from Dr. TS that the Veteran has "compensatory progressive end stage osteoarthritis of the left hip." The matters are REMANDED for the following action: 1. Please obtain updated VA treatment records. 2. Request a medical opinion, or if necessary, schedule the Veteran for an examination with an appropriate specialist, concerning his left hip disability. Prior to reaching an opinion, the examiner should review this remand decision and the case file in its entirety, including all service treatment and post-service medical records and examinations relevant to the left hip disability. The electronic claims file must be made accessible to the examiner for review in connection with the examination. The examiner should address the following: (a.) Identify the Veteran's hip conditions by (1) diagnosis or (2) functional impairment. (b.) The examiner should indicate whether it is at least as likely as not (50 percent or greater probability) that any left hip disability had its onset in service, or is otherwise the result of a disease or injury in service. (c.) The examiner should indicate whether it is at least as likely as not (50 percent or greater probability) that any left hip disability was caused by his service-connected (1) degenerative joint disease of the right knee, (2) left knee osteoarthritis, (3) stress fracture of the left tibia disability, and/or (4) right knee surgical scars. (d.) The examiner should indicate whether it is at least as likely as not (50 percent or greater probability) that any left hip disability is aggravated (worsened) by his service-connected (1) degenerative joint disease of the right knee, (2) left knee osteoarthritis, (3) stress fracture of the left tibia disability, and/or (4) right knee surgical scars. The examiner must consider and address the following notations in the Veteran's service treatment records and any impact that these in-service incidents which affected the Veteran's left side could have on left hip disability when formulating the medical opinions: (1) a February 1988 STR states that the Veteran was admitted for acute back strain and at that time it was noted that the Veteran had slight decreased anterior flexion in the hips; (2) a motor vehicle accident in November 1987 at which time the Veteran complained of pain in the left paraoevical region and over the left collarbone; (3) a May 1990 treatment record that states that a radiologic report of the left tibia demonstrated marked periosteal thickening of the posterior aspect of the midshaft compatible with a healing stress fracture; (4) a treatment note dated March 1991 states that the Veteran experienced a whiplash injury to the cervical spine that was incurred in a car accident in February 1991. The findings from the February 1991 accident revealed that at the time, the Veteran experienced pain on rotation to the left and inclination and reclination occasionally. The examiner must also address whether any left hip disability is caused or aggravated by the effects of the Veteran's knee disabilities which resulted in an altered gait. In doing so, the examiner must specifically address the private treatment records received from Dr. TS, including his February 2018 assessment that the Veteran has "compensatory progressive end stage osteoarthritis of the left hip." The examiner is reminded that caselaw states that there is nothing in the statute or regulation that requires that secondary service connection under 38 C.F.R. § 3.310 be the result of a "permanent" worsening of a condition. Put differently, the question instead is whether any left hip disability was aggravated beyond its natural progression as a result of his service-connected (1) degenerative joint disease of the right knee, (2) left knee osteoarthritis, (3) stress fracture of the left tibia disability, and/or (4) right knee surgical scars disabilities. The examiner is advised that causation and aggravation are separate questions, and therefore both theories must be addressed in the opinion. Rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). Tiffany Dawson Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Dorsey-Kwansa, Associate 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.