Citation Nr: 21065009 Decision Date: 10/22/21 Archive Date: 10/22/21 DOCKET NO. 17-02 501 DATE: October 22, 2021 REMANDED Entitlement to service connection for a right hip disorder, to include pain and weakness of the thigh (claimed as right thigh and femur condition), is remanded. REASONS FOR REMAND The Veteran served in the United States Army from May 1955 to February 1956, April 1959 to June 1960, and June 1960 to June 1963. This issue comes before the Board of Veterans' Appeals (Board) on appeal from a December 2015 rating decision issued by a Department of Veteran's Affairs Regional Office (RO). In December 2017, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. The transcript is of record. The Board remanded the case in April 2021 for further development, which has not been completed. Stegall v. West, 11 Vet. App. 268, 271 (1998). The Veteran contends that his right hip disorder is due to his military service. The Veteran's service treatment records (STRs) reveal that he sought treatment for a right hip/thigh injury due to tripping and falling onto curbing on August 7, 1960. See STR- Medical. The Veteran developed swelling in the right thigh area, which gradually subsided. On August 20, 1960, the Veteran complained of a sudden onset of pain and right thigh swelling. He was admitted and hospitalized for approximately eight days for treatment related to a right thigh hematoma. X-rays were interpreted as revealing evidence of a non-osteogenic fibroma with no evidence of trauma to the right femur. The Veteran was diagnosed with both right thigh traumatic hematoma secondary to his in-service fall and non-osteogenic fibroma of the right femur and subsequently discharged. The Veteran's STRs reveal no subsequent complaints or treatment for any other right hip/thigh issues. Clinical examination or the lower extremities was normal at the time of the entrance and separation examinations. The Board remanded this matter in April 2021 for a VA opinion. A VA opinion and an addendum opinion were completed in June 2021 and August 2021, respectively. In its April 2021 remand order, the Board directed that the examiner is to be advised that the Veteran's reports of continuing right hip/thigh symptoms from the time of military service to the present have been found to be competent and credible and this evidence must be taken into account when forming the etiology opinion. Importantly, the Board stated that a complete rationale must be provided for all opinions presented. Unfortunately, there has not been substantial compliance with the Board's previous remand directives regarding the issue of entitlement to service connection for a right hip disorder, to include pain and weakness of the thigh. Another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). The June 2021 examiner rendered a negative service connection opinion. The examiner opined that the Veteran's right thigh and femur condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. See June 2021 VA Examination. The examiner stated that the Veteran's STRs following his injury in 1960 do not include any right hip or thigh complaints, including his separation examination. The examiner noted that the Veteran's reports of continuing right hip/thigh symptoms from the time of military service to the present have been found to be competent and credible. However, while the Veteran was found to be a competent historian, she found that the medical records and evidence do not support the chronicity of care. Specifically, the examiner pointed to a VA neurology consult from December 2016 where the Veteran reported that his thigh pain stemmed from his in-service injury but also stated that "since around 2000 his right thigh started developing pain symptoms." Additionally, the Veteran has had back surgery for a herniated disc, which the examiner indicated can lead to radiculopathy symptoms in the lower extremities. The VA neurologist noted that completed nerve testing in March 2017 noted the Veteran's right thigh weakness was "unlikely caused by a femoral axonopathy" as the Veteran had intact reflexes and femoral nerve injury would not explain his muscle group weakness. The Veteran also had a right hip MRI in 2018 that showed a diagnosis of right hip trochanteric bursitis and chondromalacia. The examiner opined that "these conditions are unrelated to his thigh injury and are chronic use conditions." No further rationale was provided. In August 2021, a VA opinion was completed to clarify the June 2021 VA opinion. See August 2021 VA Opinion. The examiner noted that the prior negative opinions were accurate in stating that no documented evidence of an injury to the right hip during active-duty service would progress to the veteran's current right hip condition. The examiner noted that the Veteran's STRs, including the Veteran's separation examination, and post service medical record do not contain any documented evidence to support the Veteran's claim regarding his current right hip condition. Additionally, the examiner noted that there is no documentation of any hip condition during service that would result in the current claimed right hip condition. The examiner stated that "some objective method of assessing the Veteran's claim is central to the Independent Medical Opinion decision making process." For that reason, the examiner found that the weight of medical evidence does not support the Veteran's claim for a medical nexus for the claimed condition. In sum, while the examiner considered the Veteran's statements, as they are not supported by objective medical evidence, no nexus was established. The VA has a duty to assist veterans in developing their claims for benefits. 38 C.F.R. § 3.159. The duty to assist including providing a medical examination when necessary to decide a claim. 38 C.F.R. § 3.159(c)(4). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds the opinions are insufficient for adjudication as they do not provide adequate rationales. A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The June 2021 examiner noted that the Veteran's right hip MRI showed a diagnosis of right hip trochanteric bursitis and chondromalacia, but that "these conditions are unrelated to his thigh injury and are chronic use conditions." In August 2021, the examiner opined that "it is clear that there is no documentation of any hip condition during service that would result in the current claimed right hip condition." Neither examiner provided further explanation as to why the Veteran's in-service injury would not lead to a present hip or thigh condition. Both examiners relied heavily on the lack of continuous objective medical evidence. As the examiners failed to adequately address and explain why the Veteran's fall could not have led to his current hip or upper thigh condition, a remand is necessary to obtain an addendum medical opinion. An addendum VA medical opinion is warranted. The matters are REMANDED for the following action: 1. Obtain updated VA and/or identified pertinent private treatment records to the extent possible. If such records are unavailable, the Veteran's claims file must be clearly documented to that effect and the Veteran notified in accordance with 38 C.F.R. § 3.159(e). 2. Return the claims file to the examiner who prepared the 2021 examination reports and request that they prepare and addendum to the report which addresses the following question. Only schedule another examination of the Veteran if the examiner determines that this is necessary to provide the requested opinions. If the examiners who prepared the 2021 reports are unavailable, arrange to obtain the requested opinions from a suitably qualified health care professional. The examiner must review the Veteran's claims file and make a notation that the claims file has been reviewed. Based on a review of the record including the private medical evidence, and the examination results, the examiner must address the following: Is it at least as likely as not (50 percent or greater probability) that the Veteran's right hip disorder, to include multifocal acquired axonopathy and right hip trochanteric bursitis and chondromalacia, found on examination, was incurred in or is otherwise related to active duty? The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it. The examiner is advised that the Veteran's reports of continuing right hip/thigh symptoms from the time of military service to the present have been found to be competent and credible and this evidence must be considered when forming his or her opinion. In August 2010, November 2015, December 2015, and May 2018, the Veteran stated that he has sought treatment for his hip and femur ever since his separation from service and his thigh has grown consistently weaker over this time. In December 2017, the Veteran testified to the continuity of his symptoms and progressive weakness since service. If the examiner rejects the Veteran's lay statements or sworn testimony, then the examiner must explain why. The examiner is not to improperly discount the Veteran's lay statements and sworn testimony or mistakenly rely on an absence of medical evidence in the record to support his or her conclusions. A complete rationale must be provided for all opinions presented. If the examiner cannot provide an opinion without resorting to mere speculation, then he or she must explain why. The examiner must explain whether he or she needs more information or has exhausted the limits of current medical knowledge. The examiner must specifically address, and reconcile to the extent possible, his or her medical opinion with the October 2017 and September 2020 private medical opinions as well as the November 2020, January 2021, June 2021, and August 2021 VA medical opinions. Thereafter, and after any further development deemed necessary, the issue on appeal should be readjudicated G. A. WASIK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board V. Schmidt 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.